In May 2015, Wells Fargo & Company (Wells) hired Rosa Ramirez as a Financial Crimes Specialist. Shortly thereafter, in August 2016, Ms. Ramirez stopped working at Wells after suffering a mental breakdown following an altercation with her manager. Thereafter, due to her worsening depression and anxiety since starting her new job, Ms. Ramirez applied for short-term disability benefits and in September 2105, Liberty Life Assurance Company of Boston (Liberty) approved her claim. Later in December 2015, Ms. Ramirez was diagnosed with Bipolar Disorder, Post-Traumatic Stress disorder, Anxiety and Major Depressive Disorder. Additionally, her treating physician opined that she required a high level of care given the severity and chronicity of her mental illness. Accordingly, Ms. Ramirez was referred to Daymark Recovery Services (Daymark). Shortly thereafter, Ms. Ramirez had her initial assessment and despite some initial improvement Ms. Ramirez regressed and under her doctor’s recommendation, filed a claim with Liberty for long-term disability benefits (LTD benefits) and was approved in March 2016. In May 2016, however, Ms. Ramirez’ condition worsened as she began to experience violent thoughts and act abnormally. Accordingly, Liberty re-reviewed Ms. Ramirez’ claim and extended her disability benefits through July 31, 2016 because she was unable to perform nothing more than activities of daily living. In August 2016, Ms. Ramirez’ doctor completed Liberty’s restriction form due to her condition.
Liberty’s standard claim practices include conducting surveillance of claimants and having independent, board-certified psychiatrists review claims. Thus, on two separate occasions, Liberty conducted surveillance of Ms. Ramirez. Additionally, Liberty instructed their doctor to review Ms. Ramirez’ file to determine her disability – this was the third records review in five months. Upon this review, Liberty determined Ms. Ramirez was able to perform the duties of her Own Occupation and her claim was denied on the bases that her medical records did not reasonably support that her symptoms were of the severity to support impairments, limitations or restrictions secondary to mental health conditions. As a result, Ms. Ramirez appealed her denial and submitted additional documentation to support her appeal. Liberty sent the claim, along with Ms. Ramirez’ additionally documentation, to a disability nurse case manager (DNCM) to conduct a file review. The DNCM found that there was an absence of medication adjustment, and that there was a lack of participation in individual or group therapy. This observation, though not unexpected given the severe and impairing nature of Ms. Ramirez’ symptoms, led the DNCM to conclude that because Ms. Ramirez’ symptoms were not worsening, her mental illness, supplemented by therapy and medication, would not in and of itself support the need for restrictions and/or limitations. On these grounds, Liberty denied Ms. Ramirez’ appeal, and Ms. Ramirez filed suit against Liberty alleging the wrongful denial of her benefits under the Employee Retirement Income Security Act (ERISA). On summary judgment, the Court ruled Liberty’s denial of Ms. Ramirez’ claim was arbitrary and capricious. Accordingly, Liberty was commanded to reinstate Ms. Ramirez’ LTD benefits and pay attorney fees.
To reach their conclusion, the Court found there was substantial evidence to support that Ms. Ramirez was disabled under the terms of the policy. The policy’s language provides that when someone is deemed disabled, Liberty must continue to pay benefits if they receive continued proof of disability, regular attendance of a physician, and appropriate available treatment. Proof is defined as evidence in support of a claim for benefits, including but not limited to, a completed claim form, an attending physician’s statement, a physician’s diagnosis, chart notes, and other forms of evidence. Additionally, the policy provided that in determining a person’s disability, Liberty will not consider employment factors such as interpersonal conflict in the workplace, recession, job obsolescence, paycuts, job sharing and loss of a professional or occupational license or certification. This caveat was important because notwithstanding the ample evidence suggesting otherwise, Liberty argued Ms. Ramirez’ reason for quitting was due to conflict with her employer. The Court concluded that given the policy language, Liberty’s claim denial expressly violated the policy provisions contained in the policy due to their reliance on the conflict with the supervisor.
Moreover, not only did the court find that Liberty downright ignored the policy language to make their determination, but the materials Liberty relied upon to make said determination were inadequate to support their denial. Liberty, however, cherry-picked and misrepresented the evidence provided to support their denial and blatantly ignored the ample evidence providing that Ms. Ramirez was indeed disabled. For one, Liberty cherry-picked from various doctors’ notes and assessments concerning Ms. Ramirez that did not represent the entirety of her condition. For example, in their denial, Liberty relied upon the fact that a psychiatrist deemed Ms. Ramirez’ anxiety and depression symptoms as mild. In that same report, however, Liberty blatantly ignored the fact that that doctor reaffirmed her Generalized Anxiety Disorder and opined that although her anxiety and depression symptoms were mild, her condition had in fact worsened. Additionally, the Court found that Liberty’s reliance on Ms. Ramirez’ non-compliance with attending therapy, the surveillance videos of Ms. Ramirez, and the evidence of her medication not being adjusted, was illogical. Regarding her therapy sessions, the Court found that Liberty’s reliance on Ms. Ramirez not attending therapy is unfounded because a hallmark of bipolar disorder is lack of compliance with therapy. The Court, again, explained that in that instance Liberty cherry-picked facts to support their non-disabled conclusion and ignored the multiple opinions of various healthcare professionals who acknowledged that Ms. Ramirez’ anxiety made it difficult for her to attend therapy sessions. Furthermore, Liberty’s reliance on the surveillance videos was without merit due. In their denial, Liberty consistently argued that Ms. Ramirez was not disabled because she was seen running errands and laughing with her boyfriend although in the past she told her treating providers that leaving her house was difficult. The Court found that using these surveillance videos, Liberty again cherry-picked evidence and deflected from the fact that a few days later video surveillance of Ms. Ramirez showed her only leaving the house once to check the mail. The Court explained that these two differing instances alone suggest Ms. Ramirez suffered from bipolar disorder due to the episodic, high highs and low lows nature of the condition. Lastly, Liberty’s justification that Ms. Ramirez’ medication dosage was not adjusted was grounds for denial is also insufficient. Ms. Ramirez, at one point during her therapy, complained to her doctors that her medication was having a sedative effect on her. Liberty, however, construed this fact to mean her symptoms were improving in order to support their denial. The Court, however, found the opposite. The court reasoned that her doctors not adjusting her medication dosage because the dosage she was prescribed was necessary to treat her symptoms. As such, the Court determined that given the aforementioned reasons, Liberty’s bases for denial were without merit and Liberty cherry-picking evidence in the claim file to support its desired conclusion was arbitrary and capricious.
If you have any questions about your disability claim, we handle cases at all stages from filing the application to filing the applicaiton to suing the insurrer. Please contact us toll free at (866) 363-3628 or via email at [email protected]