This month’s Friday Five covers the treatment of job-related stress in assessing an attorney’s disability, the requirements surrounding the qualifications of a medical professional to review a claimant’s medical records in making disability determinations, the requirements for determining disability including both treatment, if needed, and an actual finding that the claimant is unable to perform duties rather than simply a diagnosis, the evidence needed to establish whether a death is “accidental”; and the treatment of long-term COVID-19-related illnesses under ERISA plans.
The Saul Ewing ERISA Litigation Team
- The Eastern District of Virginia holds it is an abuse of discretion to deny an attorney’s LTD claim on remand finding administrator did not adequately address risk of future harm could exacerbate his cardiac condition in returning to his occupation. Plaintiff challenged Defendant’s denial of long-term disability benefits after Plaintiff was advised by his doctors to stop working as a cyber-security attorney due to a heart condition and the concern that job-related stress would exacerbate that condition if he returned to work. The court initially remanded the case to Defendant to determine both whether “less stressful” positions existed and whether there was a risk of “future harm” if Plaintiff returned to his job. On remand, Defendant denied the claim. The court rejected Defendant’s position that the material duties of Plaintiff's regular occupation are not stressful, in part due to “stress [not being] one of the work situations” identified by Defendant's vocational study and the Dictionary of Occupational Titles. The court rejected this argument, noting that from the job description, “one can infer that stress may flow from a material duty without literally spelling out stress as one such duty.” The court granted plaintiff's motion for summary judgment, ordering Defendant to provide Plaintiff with back benefits and interest, as well as any other benefits required under the Plan consistent with the conclusion that Plaintiff is “totally disabled.” Aisenberg v. Reliance Standard Life Ins. Co., 2024 WL 711608 (E.D. Va. Feb. 21, 2024).
- The Northern District of Texas remands a claim finding that the same nurse could not review the claim initially and on appeal as well as lacked the appropriate credentials under ERISA regulations. Plaintiff challenged Defendant’s denial of long-term disability benefits after Defendant determined she was no longer disabled, despite having received benefits for years prior. Plaintiff argued that Defendant failed to conduct a "full and fair review" as mandated by ERISA because Defendant did not consult with a qualified health professional during the appeal process and relied on the same individual for both the initial denial and the appeal, which was not consistent with ERISA requirements. The court agreed with Plaintiff, finding that a nurse reviewing the claim initially and also on appeal was improper. Additionally, the court noted that although ERISA does not require the reviewing physician to have the exact same specialty as the claimant’s treating physician, the nurse who reviewed the claim was “not a physician” and there was no contention that she had “the appropriate training and experience.” The court therefore granted Plaintiff’s motion for partial summary judgment and remanded the case to Defendant for a full and fair review in accordance with ERISA’s procedural requirements. Black v. Unum Life Insurance Co. of America, 2024 WL 873536, – F.Supp.3d – (N.D. Tex. Feb. 29, 2024).
- The Middle District of Florida grants judgment for an insurer finding Plaintiff’s diagnosis with Alzheimer’s was insufficient to establish disability. Plaintiff challenged Defendant’s denial of short-term and long-term disability, which Plaintiff claimed based on concerns over his cognitive abilities and memory. Both the short-term and long-term disability plans required claimants to be unable to perform their “regular occupation” and to be under the appropriate care of a doctor in order to be considered disabled. The court applied a de novo standard of review to determine whether the Plan’s denial of benefits was wrong. Although Plaintiff submitted medical records with a diagnosis of Alzheimer’s disease, the court explained that a diagnosis is not sufficient to establish disability under ERISA. Moreover, there was little or no record of treatment for Plaintiff’s alcoholism, which had been recommended by providers and receiving medical treatment was a requirement to obtain benefits under the policies. Cottingim v. Reliastar Life Ins. Co., 2024 WL 1156483 (M.D. Fla. Mar. 18, 2024).
- The Northern District of Illinois affirms judgment for administrator in AD&D case. Plaintiff sued Defendant for a breach of contract, seeking a declaratory judgment. Plaintiff challenged Defendant’s denial of AD&D benefits after Plaintiff’s husband died and an autopsy found “the manner of death could not be determined.” The court explained that “Defendant's decision depended on the core question: was the death an accident?” Because the autopsy was unable to determine a manner of death and Plaintiff presented no other evidence that the death was the result of an accident, Plaintiff failed to meet her burden of establishing that Defendant’s decision was arbitrary or capricious, and the court granted Defendant’s motion for summary judgment. Wojcik v. Metropolitan Life Ins. Co., 2024 WL 1214570 (N.D. Ill. Mar. 21, 2024).
- The court awards LTD benefits to a plaintiff alleging disability due to ongoing COVID-19 symptoms. Plaintiff challenged Defendant’s denial of long-term disability benefits based on ongoing COVID-19 symptoms. The court discredited the reviewing physician’s determination of Plaintiff’s long-term disability because he (1) treated Plaintiff’s subjective reports inconsistently, taking Plaintiff at her word only when it supported denying benefits and otherwise questioning or disregarding her subjective view; (2) failed to provide his analysis of her condition as a whole; (3) ignored major ongoing restrictions and other records regarding restrictions based on an inaccurate view of the relevant time period; and (4) faulting Plaintiff for failing to provide objective evidence when Defendant recognized that Plaintiff’s condition was one that was not verifiable with tests, procedures or examinations. Because the reviewing physician’s views did not support Defendant’s denial of benefits and the record otherwise supported a benefit award, the court granted Plaintiff’s motion for judgment on the administrative record, awarding her long-term disability benefits from the time of her illness until she returned to work full time. Whitehouse v. Unum Life Insurance Co. of America, 2024 WL 1209230 (D. Minn. Mar. 21, 2024).
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