Michigan Court Agrees With Anthem's Denial of Long Term Disability Benefits

The Michigan Federal Court agreed that the plaintiff had physical limitations, but none of the activities from which she was restricted were required by her sedentary occupation Plaintiff’s initial claim for long term disability benefits was denied by Anthem. The denial was upheld following three administrative appeals. After reviewing her medical records, all three separate independent reviewers agreed that although the plaintiff’s physical activity was limited, the limitations had little bearing on her ability to work in her sedentary job as a Senior Approver at WellPoint Companies. Her job duties were to answer the phone and review and pay insurance claims.

According to her treating physician, the plaintiff suffered from severe back pain, pain in her knee due to a meniscus torn in two places and high blood pressure. He claimed she could not return to her job “in any capacity” because she could not “bend, stoop, twist, climb, push, pull, lift.”

The court agreed with Anthem that the limitations placed upon her did not preclude her from working at her sedentary job which “can be performed by alternating sitting and standing.” Since her job did not require her to do any of the activities from which she was restricted, the plan administrator gave “a reasonable explanation based upon the evidence ‘for its decision’.”

Anthem’s Denial of Long Term Benefits was Not Arbitrary and Capricious When Three Separate Reviewers Concluded That the Medical Records Did Not Support the Opinion of the Treating Physician

After listing the restrictions on the plaintiff’s activities, the treating physician simply concluded, “she cannot currently perform any of her job functions.” His opinion was that it should “be obvious” that the 5 feet 4 inches woman who was morbidly obese, weighing 371 pounds, could not work eight hours a day 40 hours a week.

Two physicians, a spine surgeon and a pain management specialist, and a rehabilitation counselor reviewed the plaintiff’s medical records and the restrictions placed on her activities. Although the reviewing physicians concluded that the medical record contained no objective evidence of a specific diagnosis, it was not relevant to the conclusion that a modification of the job should accommodate her needs. Specifically, she was capable of sitting or standing up for approximately two hours at a time alternating with “brief periods of standing or even walking for a minimum of ten to fifteen minutes.” Since her occupation was sedentary and did not require her to do any of the restricted activities, the court agreed with Anthem that there was no basis upon which to grant her long term disability benefits.

If you are having problems with your insurer concerning your application for disability benefits, call Disability Attorneys Dell & Schaefer for a free consultation.

Although our office did not handle this Michigan Federal ERISA claim for long term disability benefits, there is a lot disability claimants can learn from the unfortunate outcome of this lawsuit.