In Johnson v. Life Insurance Company of America, a Colorado District Court ruled in favor of the claimant finding LINA’s decision unsupported by any reasonable basis. The case dealt with a denial of long term disability benefits at the change in definition from own occupation to any occupation. After paying 24 months of benefits to Ms. Johnson, LINA concluded that Ms. Johnson did not qualify for any occupation benefits and ceased payment.
Ms. Johnson had been suffering from a chronic medical condition known as Trigeminal Neuralgia which causes excruciating pain and is often untreatable. She was employed by GEICO for 19 years as an auto damage field supervisor but had to cease working due to pain caused by Trigeminal Neuralgia which had progressed to the point that pain medication made it impossible for her to continue functioning at work and prevented her from driving, a major job requirement. While Trigeminal Neuralgia is often difficult to diagnose, in this case, there was no question as to the existence of Ms. Johnson’s medical condition. However, as is the case in many claims based on chronic pain, LINA challenged the assertion that Ms. Johnson could not work due to her intractable pain.
Following the initial denial of benefits, Ms. Johnson submitted an appeal. Just one month after LINA denied benefits, the Social Security administration awarded disability benefits. During the course of the appeal, LINA obtained records from the Social Security Administration that included an independent examination report. LINA also had Ms. Johnson examined by a physician who described her as “evasive.” The examiner concluded that the pain reports were unsupported, and that Ms. Johnson was significantly exaggerating her symptoms. Unsurprisingly, LINA upheld its decision to deny benefits.
After submitting a second unsuccessful appeal, litigation ensued, leading the court to review LINA’s decision and focus on several issues that had to do with credibility.
First, the court found that LINA’s initial approval of benefits and its failure to discuss that approval raised suspicion about whether its decision was adequately reasoned. After all, it is obvious that the disability due to Trigeminal Neuralgia would have impacted Ms. Johnson’s ability to perform any occupation. The court also found that LINA did not have a legitimate rationale for rejecting the decision of the Social Security Administration and LINA failed to consider the medical evidence that showed Ms. Johnson was receiving extensive treatment.
In reaching its decision, the court concluded that LINA’s doctor’s examination should not be given any evidentiary weight after observing that the examiner’s report “displays a persistently and otherwise unexplained skeptical and impatient tone.” LINA file reviews were equally as questionable given that the reviewer’s opinions were all based on a lack of “objective evidence” even though none of the doctors questioned the Trigeminal Neuralgia diagnosis.
Ultimately, the court concluded there was no reasonable basis for LINA’s determination. This case reminds us that where the diagnosis in question is unchallenged, adverse credibility decisions without any basis are unsupportable.
The case was not handled by our office, but it can provide claimant’s guidance in their pursuit of benefits under their disability insurance policies. If you need assistance with a similar matter please contact any of our lawyers for a free consultation.