Can Medical Records Created After the Eligibility Period Support a Claim for Disability Benefits?
In James s. Louis v. The Hartford Life and Accident Insurance Company (Hartford), Plaintiff was a Senior Principal Product Strategist with Oracle America Inc. (Oracle) when he was fired from his job effective October 13, 2017. Between May 2017 and the date of termination, Plaintiff worked only intermittently.
Oracle provided its employees with a long term disability (LTD) benefit plan under which Plaintiff could receive benefits if he was disabled on the date of his termination and remained continuously and totally disabled for the next 90 days. Plaintiff applied for LTD benefits claiming he was unable to work due to gastrointestinal and dermatology problems.
Both Plaintiff and Hartford agreed the elimination period ran from October 13, 2017, the date Plaintiff was fired from his job, to January 10, 2018.
Disability under the policy was defined as the inability to “perform with reasonable continuity the Essential Duties necessary to pursue your occupation in the usual or customary way.” Plaintiff was required to prove he was unable to perform his regular occupation by a preponderance of the evidence.
Hartford denied Plaintiff’s claim for LTD benefits and then denied his administrative appeal. Having exhausted his administrative remedies, Plaintiff filed this ERISA lawsuit in the U.S. District Court for the Western District of Washington.
At the beginning of the hearing, Plaintiff himself informed the Court he was withdrawing his claim based on dermatology problems and wanted to proceed only with consideration of his gastroenterology diagnoses. The Court noted that during the hearing, Plaintiff’s attorney argued for disability based on both the dermatology and gastroenterology problems, so the Court held in favor of Hartford, finding that after de novo review, Plaintiff had not carried his burden to prove he was entitled to LTD benefits for either a gastroenterology or dermatology disability.
Pre-Termination Medical Records
In support of his claim, Plaintiff submitted records of three visits with gastroenterologists during the time he worked intermittently from May 24, 2017, the first day he missed work, and October 13, 2017, his termination date.
He had three visits with two gastroenterologists: June 15, 2017, June 22, 2017, and September 14, 2017, but no visits with any dermatologist. He was diagnosed with several gastroenterology problems including ulcerative colitis, primarysclerosing cholangitis (PSC), a disease of the bile ducts.
One gastroenterologist noted Plaintiff had prior diagnoses of hidradenitis suppurative (HS) and pruritus and referred him to a dermatologist. Neither of the gastroenterologists made any mention of Plaintiff being unable to work.
Plaintiff submitted no other medical records indicating treatment occurring between September 14, 2017 and his termination date of October 13, 2017.
Medical Records from Termination Date Through the 90-Day Elimination Period
Plaintiff made no visit to any physician for the first 55-days of the elimination period. For the last 35 days of the elimination period, December 7, 2017, to January 10, 2018, he made two visits to his treating physicians. One to his dermatologist who noted Plaintiff was “clear today.” She recommended follow-up in six months.
Plaintiff visited his treating gastroenterologist complaining of diarrhea. Plaintiff told the doctor he “could not work due to loose stools.” The doctor examined him and reported Plaintiff was “in no acute distress.”
All other medical records submitted during Plaintiff’s appeal were from treatments, diagnoses, and attending physician statements (APS) that were after the elimination period. No records supported disability prior to the termination date and prior to the end of the elimination period.
Independent Medical Review
Hartford obtained a peer review report from a Board Certified Internal Medicine physician. He noted that no physician had placed any restrictions or limitations on Plaintiff from a gastroenterology perspective. The reviewing doctor himself suggested that the “claimant should have restroom access at all times.” Hartford denied the claim, but told Plaintiff it would re-review his case if he submitted medical records relevant to his dermatological issues.
Plaintiff submitted more medical records, “none of which reflected examination during the Elimination Period.” Hartford reviewed the medical records and determined that, “although later flare-ups in Plaintiff’s condition may have caused some functional impairment after the 90-day Elimination Period, the records did not support any functional impairment throughout the 90-day Elimination Period.”
District Court’s Decision Upholding Hartford’s Denial
With the agreement of both Plaintiff and Defendant, the Court conducted de novo review. Under this standard, the Court reviewed the entire administrative record, including the medical records, and made its own determination that Plaintiff had not proved beyond a preponderance of the evidence that he was entitled to benefits under the policy.
The Court found the APS reports and supporting letters from Plaintiff’s treating physicians “were all created well after the Elimination Period and fail to provide or refer to any objective evidence of disabling conditions throughout the Elimination Period (which would be expected given the objective nature of his conditions.) The APS reports and supporting letters are, therefore, unpersuasive….. Accordingly, The Hartford’s decision to deny LTD benefits to Plaintiff is upheld as a matter of law…”.
This case was not handled by our office, but we believe it can be instructive for those who apply for disability benefits after they have been fired from their employment. If you have any questions about this case, or any question about your own disability claim, contact one of our disability attorneys at Dell & Schaefer for a free consultation.
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