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Anthem Disability Claim Denial Reversed by Nevada Court

Attorney Gregory DellAuthor: Attorney Gregory Dell

District Court Proceedings

In Decovich v. Anthem, a Nevada District Court granted Anthem’s motion for summary judgment finding Anthem’s denial of plaintiff’s application for long term disability benefits was reasonable. According to the court, the “administrative record is voluminous, well-known to the parties, and its contents are not disputed.” Accordingly, the court opinion provides only a brief synopsis of what happened in the case.

Plaintiff was a dealer for the Venetian Casino Resort in Las Vegas. She quit working and claimed that she was totally disabled due the pain and distress caused by fibromyalgia. In support of her claim for long term disability benefits, several treating physicians provided reports but none placed specific restrictions on her ability to work. An independent review of the records found no objective evidence supporting her claim of total disability.

Two of her treating physicians referred her for psychiatric evaluations, but she did not follow through with either of the referrals. One treating physician reported that she was unable to stand for more than 15 minutes. This would interfere with her job as a casino dealer. The district court did not mention any other treating physician who supported her disability claim.

Ultimately, the district court agreed with Anthem’s rejection of her application for benefits on the grounds that at least two of her physicians noted she may have a psychiatric condition, but “because plaintiff neglected to pursue those physicians’ referrals for psychiatric treatment, she failed to establish the existence of a psychiatric disability.”

Anthems motion for summary judgment was granted by the Nevada District Court and the plaintiff appealed.

Decision of the U.S. Circuit Court of Appeals for the Ninth Circuit

The Ninth Circuit held that the district court erred in granting Anthem’s summary judgment motion and, contrary to the district court’s conclusion, the Ninth Circuit held that there was a triable issue of material fact. One of the plaintiff’s treating physicians reported that she “could not fulfill her requirements as a card dealer.” Another, not mentioned by the district court, said she was “unable to perform her current occupation.” The Ninth Circuit held that these two opinions were “sufficient to create a material dispute of fact.”

The Ninth Circuit also held that the District Court’s conclusion that Anthem acted reasonably in denying benefits was not consistent with the requirement that it conduct de novo review even though the district stated its review would be de novo. That court should have undertaken “an independent and thorough inspection” of Anthem’s decision.

Since the plaintiff had never requested benefits based on a mental or psychiatric condition, Anthem erred in denying her benefits on the grounds that she had not established a psychiatric disability.

The case was remanded to the district court to evaluate the case based on the proper standard of review and only on the information that was “before the administrator” at the time the decision to deny long term disability benefits was made.

If you have any questions about your disability benefits, or have been denied benefits by your insurer, contact Disability Attorneys Dell & Schaefer for a free consultation.

This case was not handled by our office, but we believe it may be instructive to plaintiff’s who are fighting against summary judgment motions brought by disability insurers like Anthem.

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