A recent ruling by a Louisiana Federal Judge illustrates the importance for a long term disability claimant to be represented by an experienced ERISA attorney throughout each and every phase of a claim for benefits. In this ruling, the Court notes that it found no evidence to contradict the insurance companies “independent” reviewers’ opinions that the claimant could return to work. As such, the Court’s decision leaves this claimant with no benefits and no avenue to get back on claim. Due to the extreme lack of medical support it does not make sense that a lawyer would actually file this lawsuit. This claimant appears to have had some medical conditions, but the claimant and his treating doctor disagreed about the extent of the claimant’s physical limitations.
Medical History and the LTD Claim Against Boston Mutual
Previously employed by Southside Machine Works, Inc. as a Machinist, the claimant was forced to leave work on June 23, 2005 due to degenerative back problems. Shortly thereafter he applied for disability benefits from Boston Mutual Life Insurance. Relying on the support of his neighbor who was also a physician who diagnosed him with severe degenerative joint disease/spinal stenosis-lumbar spine, along with the medical records of another treating physician, the claimant felt confident in his filing for benefits.
Upon receiving the claim for benefits, Boston Mutual thoroughly reviewed his claim in an effort to determine its veracity. The first thing Boston Mutual noted was that the neighbor/physician stated that his treatment of the claimant was “off the record”. The neighbor/physician was however supportive when he informed the insurance company that the claimant was “in a bad way” and “would not be able to work in a machine shop.” When Boston Mutual spoke with the other physician who had treated the claimant, they found a doctor who was not as enthusiastic of stating that the claimant was disabled. In fact, this physician told Boston Mutual that the claimant was “much improved” after taking just 3 pain pills over a month. This physician also would not provide any restrictions or limitations and stated that the claimant could return to work when he felt like it. This is a fact that essentially made it impossible for the claimant to prevail on his claim for benefits.
Boston Mutual then had a Registered Nurse look at this case. This Nurse noted that the claimant’s job as a machinist provided that he would have to lift 50 pounds and be able to use a significant amount of torque to tighten machinery. The Nurse again contacted the claimant’s treating physician to determine if he would be able to perform this occupation. The treating physician would again not put any restrictions or limitations on the claimant. Boston Mutual therefore decided to deny the claim.
The claimant appealed. With his appeal the claimant noted that he was scheduled for surgery in the upcoming months. However, medical records and surgical records were provided with his ERISA appeal. Boston Mutual ordered these records and the records from a prior recent medial branch block procedure. Boston Mutual had these new records reviewed by an outside orthopedic physician. This reviewing physician also spoke with the claimant’s treating physician. The treating physician informed the reviewing physician that he felt that the claimant could return to work at this time. The reviewing physician therefore concluded that he found “no documentation of symptoms, physical findings, or other documentation that would support R & Ls…”. Boston Mutual again denied the claim but gave the claimant an option to file an additional appeal.
ERISA Lawsuit Against Boston Mutual
Instead of filing an additional appeal where the claimant could have sent in updated medical records including updated MRI’s and the newest surgical records, the claimant decided to file this lawsuit instead. This decision to go forward with such a lack of medical support appears to have been an incorrect decision. Boston Mutual filed a motion for summary judgment whereby it asked the Judge to rule in its favor prior to trial because its findings were so overwhelmingly supported by each of the reviews it conducted and the opinion of the claimant’s own treating physician. The claimant’s attorney failed to file any response to Boston Mutual’s Motion. The Court therefore found that were no medical records in the Administrative Record contradicting Boston Mutual’s findings, and thus the Court held that Boston Mutual did not violate its discretion and upheld its decision to deny the claim.
It appears that many different avenues could have been taken to have given this claimant a better shot at receiving disability benefits. Whether it would be getting more supportive objective evidence prior to filing the first appeal, filing a second appeal to make the administrative record as strong as possible, or filing an answer to the insurance company’s motion for summary judgment, this case is illustrative why an individual needs an experience ERISA disability attorney handling the claim at all times.
It must be noted that our firm DID NOT handle this case, however, we handle many like it throughout the country. Please contact us for a free consultation and to discuss your disability claim.