Florida Court Holds Anthem Does Not Need to do Vocational Testing in Disability Denial

This ERISA case was not handled by our office, but we feel it can be instructive to others who may be in a similar situation as this claimant.

In MacDonald v. Anthem Life Insurance Company, the plaintiff, who suffered from chronic regional pain syndrome (CRPS), alleged Anthem was arbitrary and capricious in terminating her long term disability benefits on the grounds that she could work at “any gainful occupation” without conducting a new transferable skills assessment (TSA) to determine if new restrictions would prevent her from working. The court found Anthem’s reliance on the TSA already in the record was reasonable and held, “the consideration of vocational evidence is not necessary where the evidence in the administrative record supports the conclusion that the claimant does not have a disability which prevents her from performing some identifiable job.”

Case History

Plaintiff, a medical claims processor, was injured in a motorcycle accident and suffered serious soft tissue injury to her left arm. The injury did not heal well and culminated in complex regional pain syndrome (CRPS), a condition that sometimes affects an injured limb. Anthem granted her short-term disability based on her inability to work in her “own occupation.”

She was initially granted long term disability benefits which were terminated under the “any occupation” definition of disability following a number of tests ordered by Anthem and its independent medical examiner, Dr. Krost. Based on Krost’s report, Anthem identified five specific occupations she could work in based on her “education, work history and physical capability” and terminated her long term disability benefits.

On appeal, the record was replete with reports of numerous treating physicians and specialists with whom plaintiff had consulted who all agreed she had limited use of her left arm and hand due to CRPS and reported to Anthem that she was unable to work. Plaintiff argued in her lawsuit that Anthem wrongfully ignored those records. Anthem responded that it found the reports of the treating physicians and specialists “outdated, inconsistent with the rest of the medical evidence, and did not address plaintiff’s current level of functioning.” The court agreed that Anthem was entitled to weigh the conflicting evidence and resolve it against finding plaintiff was disabled.

Ultimately, the court held, “it was reasonable for Defendant Anthem Life to rely on the jobs identified in the TSA already in the record without requiring a new one. The court noted that plaintiff did not submit contrary evidence and did not contest the jobs identified in the TSA during her appeal.” The court found that, based on the evidence, the plaintiff was capable of “light and sedentary work” and since her previous employment was “not highly skilled or technical,” Anthem was not required to conduct a vocational assessment in order to determine she was not disabled under the “any occupation” definition.

If you have questions about your disability benefits, if your claim for benefits has been denied or your benefits terminated, feel free to call Disability Attorneys Dell & Schaefer for a free consultation.