The Plaintiff in this case was vice-president of Medical Benefits at BJC Healthcare when a severe back condition required her to have a spinal fusion. She was awarded short term disability (STD) benefits while she recovered. Unfortunately, she suffered serious complications following the surgery which delayed her recovery. Her application for long term disability (LTD) benefits was initially approved, but four months after approval, it was denied.
Her problems began when she ruptured two lumbar disks in 2002. She refused surgery and continued working until 2013 when the pain became too severe. In 2013, Plaintiff began treatment with Dr. Jacob Buchowski, an orthopedist.
By 2015, Plaintiff was suffering severely with back pain, including pain and numbness that initially went down into her left leg. Eventually, she experienced the same problems in her right leg. Finally, on January 16, 2016, she underwent a spinal fusion.
Plaintiff was covered under an employee disability insurance policy issued by Cigna, so she applied for short term disability (STD) benefits. Her application was approved, and she began receiving benefits effective January 23, 2016. She had numerous complications and setbacks, including a medically necessary second spinal fusion.
Cigna extended her STD benefits through July 16, 2016, the last day for STD benefits under her disability policy. On July 6, 2016, Plaintiff applied for long term disability benefits. Her application was approved on August 16, 2016. On August 18, 2016, Cigna requested more information and then denied her claim for LTD benefits on December 1, 2016. She filed an administrative appeal which was denied.
After Plaintiff exhausted her administrative remedies, she filed an ERISA lawsuit in the U.S. District Court for the Eastern District of Missouri, Eastern Division. The Court conducted a comprehensive de novo review and found in favor of Plaintiff and ordered Cigna to pay her LTD benefits from August 18, 2016, through the present. The Court also ordered Cigna to pay her future benefits to the extent she qualifies under the terms of the plan.
Dispute Over Application of the Terms of the Policy
In order to qualify for LTD benefits under the provisions of the Policy, an employee is disabled if she is unable to perform “the material and substantial duties of her Regular Occupation and cannot be receiving in excess of 80% of her indexed earnings.” Plaintiff’s job profile noted that she would have to lift weights up to 10 pounds and would have to sit up to 75 percent of the time. The parties did not dispute that after September 20, 2016, she was not receiving 80% or more of her salary. But Cigna asserted that the Administrative Record showed that Plaintiff was not disabled from December 2016 through November 2017.
Cigna argued that Plaintiff’s job was sedentary, so she should be able to “perform the sedentary work duties associated with a job like hers in the national marketplace.” For support, Cigna relied upon conclusions found in the medical reviews and vocational analyses the insurance company ordered. Cigna asserted that its “physician reviews were thorough and reliable.”
District Court Disagrees with Cigna and Orders it to Pay LTD Benefits
Both parties agreed that the proper standard of review for the District Court was de novo. So, although it was the Plan Administrator’s decision under review, the Court was not required to grant any deference to the administrator’s decision.
The District Court noted that according to Eighth Circuit precedent, “An insurer who first approves LTD benefits, then later terminates them, must show a ‘significant’ change in claimant’s condition making her no longer eligible for benefits.” The absence of changed circumstances weighs against the propriety of the insurance company’s changed position.
Accordingly, the question before the Court was “whether Plaintiff’s condition between August 2016 and December 2016 was so different from her condition when LTD benefits were initially approved in August of 2016 as to warrant the subsequent denial of her benefits.”
The Court looked at the status of Plaintiff at the time her claim for LTD benefits was approved on August 18, 2016. The administrative record at that time showed that, according to the detailed and specific medical records and reports of her treating orthopedist, Dr. Buchowski, she could not perform the material and substantial duties of her own occupation.
For evaluation of her claim for LTD benefits, Cigna submitted Ms. L.’s medical records to reviewing physicians. The District Court reviewed each report and found “The opinions of Plaintiff’s treating physicians correspond with Plaintiff’s reports of persistent pain and correspond with the treatments Plaintiff received. Plaintiff was prescribed drugs, injections, a spinal cord stimulator placement, and eventually additional surgery for her pain. While pain is difficult to quantify, the Court can evaluate Plaintiff’s course of treatment regarding that pain. It is also telling that Defendant’s own peer reviewers, and decision letters indicated that Plaintiff was suffering from functional limitations.”
Plaintiff also submitted a functional capacity evaluation (FCE) which showed she could not sit for more than one-third of the work day. She argued that since her sedentary job required her to sit for long periods of time, she was disabled from working in her regular occupation. Defendant argued just the opposite, claiming that she should be able to perform the duties of her sedentary job if she was given enough breaks from sitting. The Court noted that an FCE “can neither prove nor disprove claims of disabling pain.'”
Based on the preponderance of the evidence, the District Court ruled in favor of Plaintiff and specifically concluded: “The medical evidence presented by the Plaintiff cannot be outweighed by the inconclusive results of her FCE. The Court therefore finds that Plaintiff was continuously disabled following the initial approval of her LTD benefits. Plaintiff has established that the Defendant’s decision to not pay Plaintiffs [sic] disability benefits once she was no longer earning 80% of her indexed salary was erroneous under the terms of the Plan and in light of all of the evidence presented. The Court will therefore enter Judgement [sic] in favor of the Plaintiff.”
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If you have been denied STD or LTD disability benefits by Cigna or any other disability insurance company, or have any questions about your disability claim, please do not hesitate to contact any of our lawyers at Dell & Schaefer for a free consultation.