Johnson&Johnson Employee with Depression Denied Disability Benefits After Definition Change
This Johnson & Johnson disability denial lawsuit and its result shows why an experienced disability attorney is often needed prior to a disability claim denial. If the claimant in this case had hired a representative earlier in the case to assist her with her claim and administrative appeals, there is a chance that the court would have had more medical documentation in support of her claim and thus perhaps resulting in a more favorable ruling.
Employee Forced to Leave Work Due to Depression
In February 2008, an employee of Johnson & Johnson was forced to leave work due to depression. She immediately applied for and was approved for Short Term Disability Benefits. As the claim was transitioning from a short-term claim to a long-term claim, Reed Group, the third party administrator of Johnson & Johnson’s disability policies, had the claimant undergo an independent medical examination by a psychologist. After initially being awarded Long Term Disability Benefits, Reed Group denied continued benefits in September of 2008 because the initial reviewing psychologist found that the claimant was exaggerating her symptoms and gave a poor effort throughout testing.
The Claimant filed an administrative appeal. As the appeal was pending, Reed Group had a board certified psychiatrist conduct an independent review. That reviewing physician concluded that the claimant was not able to work in any capacity. In light of this opinion, LTD Benefits were reinstated on October 13, 2008.
In March of 2009, a third evaluation was conducted whereby the doctor concluded that the claimant was not able to return to work in any capacity. The Social Security Administration agreed and awarded disability benefits to the claimant.
Change in Definition of Disability Results in Disability Denial by Reed Group
In the spring of 2009, the definition of disability changed in the policy. The earlier definition of disability stated that the claimant had to be unable to perform her job. The new definition required that she be unable to perform any job in order to qualify for continued disability benefits. It must be noted that the change in definition of disability is very common and found in the great majority of today’s ERISA disability policies.
In light of the higher standard the claimant now needed to meet, Reed Group reinvestigated the claimant’s case. In May of 2009, the claimant was sent to a Psychologist for an independent medical examination. Following this IME, Reed Group terminated the claimant’s continued receipt of benefits. Apparently this psychologist found that the claimant’s subjective complaints could not be objectively verified.
The claimant again appealed. In response to this appeal, Reed Group had the claimant’s file reviewed by an independent reviewing psychologist. Relying on this “independent review”, Reed Group upheld its decision to deny benefits on October 12, 2009.
Two months after the latest denial, the claimant retained counsel to assist her with her final administrative appeal. This focus of the administrative appeal was the initial independent reviews that found that the claimant was not able to work in any capacity. In response to this appeal, Reed Group submitted the entire file to another psychologist for another independent evaluation. Using this review for support, Reed Group again denied the claimant’s claim. Reed Group also stated that the reports the claimant points to in her appeal addressed an earlier time period.
Following this final denial, a lawsuit ensued.
ERISA Disability Lawsuit Filed Against Johnson & Johnson and Reed Group
Without further administrative remedies available, the claimant was forced to file an ERISA lawsuit. Unfortunately for the claimant, the ERISA statutes severely handcuff the Federal Court in ERISA Claims. In fact, even if a federal court believes the decision to deny benefits was wrong, “the ultimate question… is whether reasonable ground supported that decision; in other words, whether Johnson & Johnson’s decision to deny (claimant’s) benefits was arbitrary and capricious.”
The Court found that Johnson & Johnson’s decision to give more weight to the objective data and the “independent” doctors rather than the claimant’s treating doctors was neither arbitrary nor capricious. Similarly, the Court found Johnson & Johnson’s explanation that the supportive reports the claimant pointed to in her final appeal were from a different time period was reasonable.
In the end, the Court found that Johnson & Johnson’s decision to terminate was reasonable and ruled in favor of Johnson & Johnson.
What If…
The facts of this case leave open the question as to how the Court would have ruled if more supportive documentation and objective evidence was presented to the Court by the claimant. Although our firm did not represent the claimant in this case, nor have we had a chance to review all the documentation from the case, the Court’s Order shows that insufficient contrary evidence was presented that could have swayed the Court to have found that Johnson & Johnson’s decision was in fact not reasonable. For instance, if the claimant had an attorney involved sooner other medical examinations, testing, etc., could have been done and presented to combat the “independent” reviews which were paid for by Johnson & Johnson.
If you have a case with similar facts or if you have a claim that is currently under review by a disability insurance company, please contact us so that we may provide you with a complimentary consultation.
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Sedgwick
Very very slow to respond
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