Anthem Disability Claim Denial Reversed by Nevada Court

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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We represent Anthem clients nationwide and we encourage you to contact us for a FREE immediate phone consultation with one of our experienced disability insurance attorneys.

Can you help with a Anthem disability insurance policy?

Our disability insurance lawyers help policy holders seeking short or long term disability insurance benefits from Anthem. We have helped thousands of disability insurance claimants nationwide with monthly disability benefits. With more than 40 years of disability insurance experience we have helped individuals in almost every occupation and we are familiar with the disability income policies offered by Anthem.

How do you help Anthem claimants?

Our lawyers help individuals that have either purchased a Anthem long term disability insurance policy from an insurance company or obtained short or long term disability insurance coverage as a benefit from their employer.

Our experienced lawyers can assist with Anthem:

  • ERISA and Non-ERISA Appeals of Disability Benefit Denials
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After collecting LTD from Prudential for about 16 months, I was cut off without warning. At the time of being cut-off, I was recovering from my 4th back surgery. I had numerous, bulging disks, nerves that were severely impinged, diskectomy from C2-C7, and active arthritis and degenerative disk disease throughout my spine. While being out of work, I also developed pulmonary fibrosis as well as COPD and have a difficult time breathing. I went through numerous sessions of physical therapy, Spinal Cortisone Injections, Trigger Point Injections, a Neurostimulator Implant, as well as a battery of strong narcotics to control the pain.

I was declared totally and permanently disabled by my neurosurgeon as well as being awarded Social Security Disability. There was no way I could work any job, let alone my previous job. After a brief talk with Alex Palamara, Dell & Schaefer offered to take my case. I was amazed at the level of personal and medical detail Alex knew about my case. Alex was able to assemble a solid appeal. I was turned down for LTD again! Alex fought even harder! After the second appeal, we were able to make Prudential “understand” my medical condition and how it affects my ability to perform work. I feel very comfortable knowing Alex and Dell & Schaefer are in my corner going forward!

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