Hartford Prevails in ERISA Lawsuit Demonstrating ERISA Law can be Unfair for Claimants
The ERISA Law Governing Disability Insurance Claims Favors Insurance Companies
The law that governs lawsuits brought for denial of short or long-term disability benefits through a claimant’s group disability insurance policy with their employer is called ERISA. When a lawsuit is governed by ERISA, the legal process is entirely different than one might imagine because lawyers rarely get to argue their case in front of a judge and you, as a claimant, will never get your “day in court”. This is very important to know when you contemplate filing a disability lawsuit because, due to the way disability insurance policies are written and the law under ERISA, the cards are often stacked against claimants. What is at issue in an ERISA lawsuit is not only whether or not a claimant is truly disabled and should be entitled to disability benefits, but rather, it is more often a matter of whether or not the disability insurance company complied with the terms of the Plan and the law under ERISA when making its decision.
A good example of how the ERISA law can be unfair for claimants is a recent case in New Jersey where a claimant, McCann, filed a lawsuit against Hartford for wrongful termination of his long-term disability insurance benefits. Hartford initially approved McCann and found that he was entitled to benefits due to his disability caused by his diagnosis of an aortic aneurysm. Hartford paid McCann disability benefits for 2 years before determining he was no longer disabled under the plan’s definition of disability and his benefits were terminated. McCann filed an administrative appeal, but, despite presenting additional medical documentation as evidence of his continued disability, Hartford upheld their decision to deny continued long-term disability benefits. Thereafter, McCann filed his ERISA disability lawsuit.
Discretionary Standard of Review
McCann’s disability insurance policy contained certain language, which is found in most disability policies, and granted Hartford – the Plan administrator – “full discretion and authority to determine eligibility for benefits and to construe and interpret all terms and provisions of The Policy.” When an ERISA disability policy, or plan, grants the administrator (Hartford) discretionary authority to determine eligibility for benefits, the job of the court is to analyze the administrative record and determine whether the decision to terminate benefits was supported by substantial evidence, or whether the decision was “arbitrary and capricious.” The Court’s job in this case was not to make its own judgment as to whether it thought McCann was disabled, but instead it had to determine if Hartford properly considered the evidence it had, such as McCann’s medical records and physician statements, and made a reasonable decision which is supported by that evidence to terminate McCann’s benefits.
McCann argued that Hartford’s decision to terminate long-term disability benefit payments was arbitrary and capricious for the following reasons: 1) Hartford reversed its position as, at first, benefits were approved but then were later terminated; 2) Hartford did not consider all of the relevant diagnoses; 3) they did not properly consider McCann’s ability to perform the Essential Duties of his Occupation; 4) they improperly relied upon reports of their own hired physicians who reviewed McCann’s medical records; and 5) there was a conflict of interest because Hartford both funded and evaluated claims.
Court’s Review of the Administrative Record
Another significant difference when a lawsuit is governed by ERISA is that the Court is only allowed to review the documents that the plan administrator had available to review at the time the final denial of benefits was made. This is known as the “administrative record”, and it contains the medical records that were submitted to or obtained by the insurance company, the claims notes, correspondence between the insurance company and the claimant, the policy documents and any other documents regarding the insurance company’s investigation into your disability claim. The fact that the Court is only permitted to review and consider the administrative record is inherently unfair for claimants because, once the final denial is made by the insurance company, you cannot introduce to the Court any new medical records, physician statements, or any other evidence which might help support your claim for disability.
In this case, the Court found that, even though Hartford had initially determined that McCann was disabled under the plan’s definition of disability, based on the record evidence, it was reasonable for Hartford to later determine that McCann was no longer disabled and terminate his benefits. The law recognizes that, even though it may be viewed with suspicion when benefits are first approved but are then later terminated, it is not improper as long as the decision to terminate is based on some new form of evidence. The Court reviewed the events that occurred between the benefit approval and the final denial. The administrative records showed that during that time, Hartford obtained updated medical records, had an Independent Medical Examination performed of McCann, obtained statements from McCann’s treating physicians, and had experts in the proper medical specialties review McCann’s medical records. Hartford’s decision to terminate benefits after the fact was based on new evidence and developments in the claim, and therefore, the Court found that the decision was reasonable (regardless of whether that decision was to terminate benefits).
McCann argued that, when the initial termination of benefits was made, Hartford did not consider his secondary diagnosis of sleep apnea, and that Hartford wrongly identified his occupation as a “Radiologist”, instead of an “Interventional Radiologist”, who performs substantially different duties. However, in his appeal McCann pointed these errors out to Hartford. Accordingly, when reviewing the claim upon appeal, Hartford did in fact take into account his diagnosis of sleep apnea and did perform an analysis of his occupational duties as an Interventional Radiologist. The Court noted that its task was to review the final, post-appeal decision. The fact that the initial decision to terminate benefits was made based upon incorrect or incomplete information was immaterial because Hartford corrected these errors upon appeal and the final, post-appeal decision did take into consideration the secondary diagnosis and correct occupational duties.
Hartford utilized physicians it hired to review McCann’s medical records and give an opinion, without ever examining or meeting him, as to whether or not his medical condition rendered him unable to work in his occupation. Disability insurance companies often employ this practice and the Courts have long-concluded that plan administrators who are granted authority to determine eligibility for benefits may not only rely on the opinions of non-treating physicians, but they may also give greater weight to the opinions of those hired non-treating physicians than those of the claimant’s own doctors who have been treating him or her for years. This poses a huge hurdle for claimants to overcome. McCann would have to prove that the hired physicians had not properly considered all of the medical records and test results or that they were not of the proper medical specialty (ie, an orthopedic specialist giving an opinion about a cardiac condition). The Court determined that the physician reviews Hartford relied upon were proper and all of the medical evidence was considered, and therefore, Hartford did not act unreasonably in relying upon them. Further, the Court found that prior to rendering its final decision to uphold the termination of benefits, Hartford was not required to provide McCann the opportunity to review the opinions of the hired physicians or provide a rebuttal to those opinions.
Was the Decision to Terminate Benefits Reasonable?
Even though the Court acknowledged that a potential conflict of interest may exist in this case because Hartford both determined a claimant’s eligibility for disability benefits, and paid those benefits, it determined that Hartford did not act improperly by reversing its position and terminating McCann’s long-term disability benefit payments. The Court found that Hartford acting properly when considering McCann’s relevant diagnoses and occupation, and properly relied upon opinions of their hired experts. The Court viewed these factors as a whole and concluded that Hartford’s decision to terminate benefit payments was reasonable and based on substantial evidence and, therefore, not arbitrary and capricious.
Attorneys Dell & Schaefer did not represent Mr. McCann in his disability lawsuit. But this should serve as an example of why it is so important to hire a qualified disability attorney with experience in handling ERISA lawsuits. It may be an uphill battle for the little guy to win a disability lawsuit against a big, corporate insurance company, but it is not impossible. The experienced disability lawyers at Dell & Schaefer have a proven track record of securing hundreds of thousands of dollars in disability benefits that their clients rightfully deserved. If you have questions regarding your claim for disability benefits, or if your disability claim has been denied, feel free to call Disability Attorneys Dell & Schaefer for a free consultation.
Resources to Help You Win Disability Benefits
Get Your Hartford Disability Application Approved
Prevent a Hartford Disability Benefit Denial
Negotiate a Hartford Lump-Sum Settlement
Our goal is to negotiate the highest possible buyout of your long-term disability policy.
Policy Holder Rating
Q: My employer terminated me 11/14/23 while my LTD claim is being appealed by the Hartford. Does my appeals process get terminated as well?
Hartford Denies Disability Benefits To Home Depot Employee 3 Weeks Before Change of Disability Definition
Court Finds Video Surveillance Renders Claimant’s Self-Reporting Unreliable and Upholds Hartford’s Termination of LTD Benefits
Reviews from Our Clients
Very satisfied with the work of this team. Took well care of my case and took all the necessary time to be responsive and attentive when I had questions. Guided me through recovery and returning to normalcy. All thanks to Jason & Tabitha, thank you!
I’m extremely satisfied with the experience I have had with this firm from day one. The lawyer who has handled my case, Alex, is very efficient and attentive to all my questions and concerns. They are always aware of how my case has gone and they care about my health. I feel optimistic with them because they are very attentive during the process of my claim. I would not hesitate to recommend families and friends if in any situation they need their services. Kathleen as well has been very well and assisted me with this case. I highly appreciate everything they have done for me.
It’s unfortunate when disability insurance companies come after older disabled policyholders just to help their bottom line. It can be a living nightmare the damage they can do to a family. Dell Disability Lawyers are polite, understanding and knowledgeable. They call you back and answer any question you have no matter how unimportant it can be. The amount of stress they took off of myself and family was incalculable. I recommend them highly to take care of any disability case whether it be filing for benefits or reversing a claim decision. They are outstanding.
I could not have been happier or more appreciative of the hard work they performed on my behalf. I was well briefed on my case and it was closed in a timely manner with a financially successful resolution.
Mr. Symonds and Sonia as well as everyone else we have worked with throughout this process have been very helpful, professional and caring to our situation. We are very thankful to have this great team on our side.
Without them my LTD company was dropping my plan with me still suffering from my accident, even with doctor’s statements I’m still disabled. The LTD company didn’t want to advance my policy to the next stage of years of pay. Dell Disability Lawyers saved my policy, and helped to enforce the LTD company’s own policy (for its policy holder, me) that I would be covered still under the LTD policy I had paid for at my previous job, when my accident occurred. These lawyers know what they are doing and can help you too. LTD companies will try to drop you when you still need coverage just because they don’t want to pay on your policy anymore. Don’t let them break contract with ya because they are trying to get out of it. Hit em with legal action to ensure the continuation of your policy you paid for. Dell Disability worked very well for me and continue to do so.
I was denied long term disability benefits from The Hartford after being on it for years. I found Dell Disability Lawyers after doing research online. In a matter of days they responded and explained to me everything that would be done. Dell Disability Lawyers were able to settle my suit against The Hartford very quickly and responded to me quickly. I would definitely recommend this team of lawyers for anyone that is fighting for their disability insurance.
I have had nothing but a great experience with Dell Disability Law Firm. Mr. Alex Palamara and his team went above and beyond my expectations. They will respond to emails and phone calls in a timely manner. Thank you once again for taking my case.
This law firm is the best so far. MetLife denied me two times, they appealed two times for me and they won of course. So if you are on disability and want a chance at winning your case use this firm Dell disability lawyers, kind courteous understanding and they get the job done. You won’t be disappointed.