Most individuals who have filed any type of insurance related claim have experienced the delay and denial tactics used by their insurance company to avoid payment. Disability carriers often take extreme and arguably egregious measures to “prove” that a claimant is not disabled under the terms of their disability policy. In a recent case, the US District Court for the Northern District of California found Reliance Standard Life Insurance Company’s (RSL) denial of benefits wrong and ordered the company to reinstate the Plaintiff’s benefits.
The case, Cheri Parr v. First Reliance Standard Life Insurance Company came before the Court on Plaintiff’s Motion for Summary Judgment, seeking to overturn the prior court’s granting of RSL’s Motion for Summary Judgment which upheld its denial of benefits. The Plaintiff originally submitted her claim for disability benefits in October 2011. She was a Sales Manager, deemed to be a sedentary occupation by RSL, and sought benefits under the “regular occupation” definition of the policy. Under that definition, Ms. Parr would be eligible for benefits if her disabling medical conditions prevented her from performing the duties of her regular occupation. Benefits were granted and paid. However, the policy definition changed to any occupation in October 2013 (inability to perform the duties of any occupation for which you are reasonably suited based on education, training, and experience) and RSL began looking for ways to terminate benefits under that definition. They began conducting surveillance on her in 2012, during which time she was observed engaging in short periods of modest activity on two occasions over a three day period. They also had her case reviewed by an in house nurse who concluded that Ms. Parr lacked the ability to work with consistency due to her medical conditions. Additionally, Ms. Parr’s own physicians submitted medical records and statements explaining her limitations and why she cannot work. Despite this obvious evidence, RSL had the claim reviewed by two other consulting physicians, both of whom found her to be able to return to work in a sedentary occupation, and they scrutinized her social medical forums for any evidence that she was active. RSL terminated her disability benefits in March 2014 on the ground that she was not “totally disabled” under the “any occupation” standard.
Ms. Parr appealed the denial of benefits. RSL reviewed the appeal and advised that its initial claim decision was correct and that she had now exhausted her administrative remedies. A lawsuit was filed under ERISA (Employee Retirement Insurance Act of 1974) and brought in federal court. Generally, an insurance company decision is given deference by the Court (the denial must not only be wrong, but arbitrary and capricious, for the Court to reverse the decision); however, in this case the de novo standard of review (preponderance of the evidence) was applied because the plan in question did not give the administrator or fiduciary discretionary authority to determine eligibility of benefits or construe the terms of the plan. However as with all ERISA claims, the court’s review was limited to the evidence contained in the administrative record. The Court considered the opinions of the Plaintiff’s treating physicians as well as those of the physicians hired by RSL to review the claim. The Court noted that it is not required to give greater weight to the opinions of the Plaintiff’s treating doctors. Nonetheless, the Court found the opinions’ of the Plaintiff’s treating doctors to be more reliable and probative. They noted that RSL improperly discounted the importance of her chronic pain, and its impact on her functional abilities and noted that RSL failed to point to any specific examples of her treating doctor’s notes that were inconsistent.
The Court also took into consideration the surveillance video and found that it did not support RSL’s determination that the Plaintiff was not disabled under the “any occupation” definition of disability. They held that the sparse, outdated surveillance, which showed the Plaintiff engaged in modest and isolated activity, did not provide evidence that she could consistently work at least 21 hours per week. They also found that the social media surveillance did not support the denial of evidence. The fact that the Plaintiff traveled three times in three years to visit a friend, attend a funeral, and attend a medical conference, is also not evidence that the Plaintiff has the capacity to consistently work on a full time basis. Basically, the Court saw through the tactics used by RSL in its attempt to deny the claim and undermine the Plaintiff’s credibility and overturned the denial of benefits.
If you have questions about a pending, current, or new claim please feel free to contact us for a free consultation. The attorneys at DI Law Group. Our attorneys will be happy to discuss your claim with you and your rights under your policy. We can be reached at (866) 363-3628 or through our website www.dilawgroup.com