HM Life and Broadspire wrongfully deny disability insurance benefits to a receptionist and 9th Circuit Court of Appeals reverses claim denial

When Barbara Sterio’s disability attorney presented arguments on February 11, 2010 before the Ninth Circuit United States Court of Appeals, he was unsuccessful in convincing the court to review her denial of benefits under the de novo standard of review. But the three judges reviewing Sterio’s claim, found that even though the District Court had been correct in choosing to use the abuse of discretion standard of review, that standard had not been applied correctly. A review of the background behind Sterio’s disability benefits application will demonstrate why the Court of Appeals reversed the decision of the District Court.

Sterio had been a receptionist whose employer offered an employee long-term disability benefit plan administered by HM Life. She had hip replacement surgery in 1975. It was the first of a series of many hip revision operations. In January 2000, she underwent her most recent total hip revision. She then developed postoperative complications after the surgery, including sciatic pain and numbness and weakness in her right leg and foot. Due to these post-operative complications Sterio finally stopped working in December 2000.

Sterio applied for Social Security disability benefits. Social Security determined that she was permanently disabled, and approved her application in January 2002. Then she went on to apply for long-term disability benefits with HM Life, which both insured and administered Sterio’s long-term disability plan.

HM Life hired Broadspire Services, a third party administrator, to process Sterio’s claim. Broadspire ordered six independent reviews of Sterio’s medical records. All six of the physicians concluded that Sterio was not disabled. Broadspire denied her claim, and HM Life denied her appeal because the insurance company had concluded that her objective medical evidence did not support the disability claim.

Sterio’s disability attorney filed suit in District Court. After a bench trial, where the two sides presented arguments before the judge without a jury present, the judge concluded that HM Life had not abused its discretion in the light of “conflicting evidence.” Sterio’s disability attorney appealed this decision.

Disability attorney argues that the wrong standard of review was used.

The three judges sitting on the bench for the 9th Circuit Court of Appeals reviewed the District Court’s choice of application of the standard of review. Sterio’s disability attorney argued that the Court should have applied a de novo standard because HM Life did not have a “plan” document. Instead, the disability insurance company only provided Sterio with an insurance policy. The Court rejected this argument, stating that the insurance policy was the “plan” document.

Sterio’s disability attorney also argued that Broadspire, not HM Life, had initially denied her claim. The Court ruled that because HM Life made the final denial upon appeal, Broadspire’s involvement was insufficient to make a de novo review necessary. This was a minor procedural violation of ERISA that didn’t warrant altering the standard of review.

Court rejects disability attorney’s arguments and upholds abuse of discretion standard.

The three judges sitting on Court of Appeals reached the conclusion that the District Court had correctly concluded that an abuse of discretion standard applied to HM Life’s denial of benefits. The long-term disability plan clearly gave the administrator discretion.

The question that the Court had to ask was this: “Did the District Court judge apply the abuse of discretion standard correctly?” In order to be applied correctly, the judge must pay attention to “the nature, extent and effect on the decision-making process of any conflict of interest that may appear in the record.” There are specific factors that the court must weigh in order to determine whether the insurance company has abused its discretion.

The Court of Appeals had an advantage over the District Court. A decision had been handed down by the Ninth Circuit after the District Court entered judgment. This case, known as Montour v. Hartford Life & Acc. Ins. Co., provided additional guidance in how to apply the abuse and discretion standard. See previous article in which the Montour v. Hartford case is discussed. The Court of Appeals went on to apply this process.

Court of Appeals looks at the medical evidence for disability.

First, the Judges looked at the quantity and quality of the medical evidence supporting Sterio’s disability. HM Life had rejected Sterio’s claim because the disability insurance company stated that there was no objective medical evidence to support her disability. However, the facts demonstrated otherwise.

• An EMG test confirmed that she had sciatic neuropathy in her right hip after the revision surgery.
• Two MRI exams revealed that she had excess metal artifacts in her pelvic region.
• Two x-ray exams confirmed that the bones in her right foot were thinning
• Numerous entries in her medical record confirmed that she was taking strong pain medication.
• A functional capacity evaluation (FCE) from her treating physician reported that she was unable to sit, stand or walk for more than one hour a day.
• Both of her treating physicians concluded that she was permanently disabled. This was backed up by the neurologist who treated her and two orthopedists.

HM Life was unable to explain why this credible medical evidence failed to support her disability.

Court of Appeals looks at Social Security disability determination.

Second, the Judges looked at the Social Security disability determination. While HM Life was not obligated to make the same decision, it did have to explain why the disability insurance company reached an opposite conclusion. In most cases, if an insurance company can point to differences within the policy for how disability is determined that contrast with Social Security’s guidelines, the Court will still find the decision reached by the disability insurance company reasonable.

Instead, it appeared that HM Life had completely disregarded the Social Security disability benefits determination. The disability insurance company failed to explain why it rejected Social Security’s findings that Sterio was totally disabled. The court found that this suggested that HM Life had failed to consider relevant evidence.

Court of Appeals looks at HM Life’s medical evaluations.

Although the Court recognized that HM Life’s plan did not require the disability insurance company to conduct in person medical evaluations, when the amount of evidence supporting Sterio’s claim of disability seemed so convincing, the Judges questioned whether HM Life had been thorough and accurate in reaching their benefit determination. While the file had been reviewed by six doctors, it was not clear that these physicians had all of the relevant information needed to reach a proper conclusion.

None of the six doctors mentioned Social Security’s conclusion of total disability in their reports. This suggested that none of the physicians had seen this information.

Court of Appeals looks at the thoroughness of disability insurance company’s investigation into claim.

The court found evidence that HM Life failed to conduct an adequate investigation. HM Life failed to secure a copy of the Social Security disability file, or to ask Sterio to do so. In addition, HM Life failed to provide instructions on what specific evidence the disability insurance company needed in order to reverse its denial of benefits. The physicians who reviewed her file pointed to specific medical evidence that was lacking to support her claim.

• The lack of a bone density scan caused one physician to dismiss Sterio’s osteoarthritis diagnosis.
• The lack of specific examinations, X-rays and evaluations to support the information provided in the functional capacity evaluation caused another physician to discredit her disability.

HM Life failed to tell Sterio that this information was needed to confirm her disability.

Court of Appeals looks at reason for denying long-term disability benefits.

The initial reason HM Life gave Sterio for denying her long-term disability application was her failure to prove that she was disabled after her hip surgeries. In the disability insurance company’s final decision after her appeal, the insurance company added another reason for denying her disability benefits. The insurance company claimed that because she had been hospitalized for two mental breakdowns, and had not been considered disabled because of her hip problems at the time, she was excluded because of the mental health limitation which ended at 24 months.

The Court found this procedural irregularity significant. Adding a new reason for denying benefits, when Sterio had no further appeals available, suggested a serious conflict of interest. Disability insurance companies are notorious for adding new reasons for claim denial at the appeal level. Unfortunately, the administrative record is closed after the final appeal and the claimant is at a significant disadvantage. Fortunately, the Ninth Circuit Court Appeals did not let HM Life get away with their wrongful claim handling tactics.

Court of Appeals concludes that HM Life abused its discretion.

When all of these factors were considered, the Court reached the conclusion that HM life had abused its discretion when it denied Sterio benefits. Unlike the District Court, the judges on the Court Of Appeals did not conclude that there was conflicting evidence. They found the evidence conclusive.

The Court of Appeals looked at the same evidence. Why were the results so different? The Court of Appeals has three judges looking at the evidence. This means that Sterio benefited from the wisdom of three experts in the application of ERISA legal guidelines. She also benefited from the recent Montour v. Hartford ruling that added substance to how an abuse and discretion review should be conducted.

This is one of the reasons why it can be worthwhile to make an appeal if the District Court sides with the disability insurance company. The Court of Appeals sent Sterio’s case back to the district level, where the District Court was ordered to determine the amount of retroactive benefits HM Life owed Sterio, as well as authorizing Sterio’s disability insurance attorney to present a bill for his attorney fees. The court was also ordered to determine a reasonable amount of prejudgment interest compensation.