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California Court Finds Anthem’s Long Term Disability Denial Unreasonable

Attorney Gregory DellAuthor: Attorney Gregory Dell

In McIlhaney v. Anthem Life Insurance Company Long Term Disability Plan, a California Federal District Court held that Anthem was “unreasonable” in its denial of long term disability benefits to its claimant when the medical records supported her claim for benefits and Anthem made a mistake in its reading of plaintiff’s Activities of Daily Living (ADL) report which contributed to its denial decision.

This case was not handled by our law office, but we felt it is instructive to those pursuing claims for long term disability benefits when the Plan Administrator is acting unreasonably.

Brief History

In September 2007, plaintiff was diagnosed with Legionnaire’s Disease and pneumonia. Dr. Jeffrey Galpin became her treating physician and she was granted short term disability benefits. When the short term benefits ran out, she still suffered from depression and inability to work associated with her Legionnaire’s disease, so she applied for long term disability benefits.

In evaluating her claim, Anthem ordered a medical record review by its registered nurse who concluded there was no objective evidence to support her claims of disability. The nurse also concluded that plaintiff’s claims of cognitive problems, such as memory loss and inability to concentrate, were inconsistent with her reported activities of daily living (ADL) which included her ability to walk, drive, care for her children and help her daughter with homework. She also claimed she suffered from headaches and generalized body pain.

Next, Anthem ordered a review by a board certified internist and licensed psychologist. The two professionals issued a joint report, both concluding the medical record did not provide any objective evidence to support her claim for benefits. Based on the three record reviews, her application was denied and she filed an administrative appeal.

Anthem’s Administrative Appeal Denial of Long Term Disability Benefits

In response to plaintiffs appeal, more peer reviews of medical records were ordered. One by a board certified infectious disease specialist, Dr. Bono, who also concluded there was no objective medical evidence to support her claim of disability.

A review by a board certified psychiatrist, Dr. Schroeder, also ordered by Anthem, found that plaintiff’s treating psychologist, Dr. Fitch, contained “objective medical assessments” that supported a finding of psychiatric disability. Anthem reviewed both reports and denied her appeal.

The Federal District Court Holds Anthem’s Denial is “Unreasonable”

The Federal District Court held that Anthem’s denial of plaintiff’s application for long term disability benefits was “unreasonable based on the evidence presented during the administrative claim and appeal process.” It based its ruling on:
1. The report of Anthem’s own reviewing psychiatrist who found plaintiff was psychiatrically disabled and was under the care of a psychologist.
2. The consistent reports of her treating physician, Dr. Galpin, who stated she was suffering from depression “associated with her recovery from Legionnaire’s disease.” Furthermore, Dr. Galpin never released her to return to work.
3. Earlier medical records showing that plaintiff continued to work despite a number of debilitating medical ailments.
4. The erroneous statement in Anthem’s denial letter which reported that the plaintiff coached her daughters sports teams and “went camping” when plaintiff’s actual statement was that she used to coach the teams but “am unable to physically and mentally.” As for camping, she had reported she could not “since I don’t feel good…”. Whether the mistake by Anthem was inadvertent or not, it contributed to the denial of benefits.
5. Evidence that the Social Security Administration (SSA) approved her application for disability benefits.

If you are concerned or have questions about disability claims, feel free to call the office of Disability Attorneys Dell & Schaefer for a free consultation.

Read more about Anthem disability claims.



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