The claimant, Ms. Petrone, worked for a subsidiary of Johnson & Johnson as a Finish Operator for 7 years. She stopped working after she was diagnosed with a L5-S1 disc herniation and underwent back surgery, a lumbar laminectory, which failed and left her with continued post-surgical pain and radiculopathy. Ms. Petrone was approved for short-term disability benefits and then received long-term disability benefits for nearly 2 years before the Johnson & Johnson plan administrator determined she no longer met the Plan’s definition of totally disabled. Despite an approval of Social Security Disability Benefits, Johnson and Johnson continued to refuse to pay long term disability benefits.
The Massachusetts Court reviewed the administrative record and found that Johnson & Johnson abused its discretion in denying Ms. Petrone’s claim because it failed to address substantial medical evidence in the file which supported that Ms. Petrone was, in fact, totally disabled. Additionally, Johnson & Johnson also abused its discretion by construing the evidence to determine that Ms. Petrone failed to cooperate pursuant to the terms of the Plan.
Ms. Petrone’s three treating physicians, expert occupational therapist, and independent vocational consultant, as well as the physical therapist retained by Johnson & Johnson to perform a FCE, concluded that Ms. Petrone’s disability prevented her from performing even “sedentary” work. An Administrative Law Judge for the Social Security Administration submitted a report finding Ms. Petrone disabled. Additionally, Ms. Petrone, her sister and her partner, all submitted sworn statements regarding Ms. Petrone’s disabling condition and her limitations in her ability to function.
Johnson and Johnson Ignores Medical Evidence Submitted by Former Employee
In its final denial letter, Johnson & Johnson failed to address any of this contrary evidence. Although a plan administrator is not required to rely on the opinions of the claimant’s treating physicians, they cannot completely ignore or dismiss contrary evidence without explanation. Johnson & Johnson addressed the sworn statements and indicated that they would be given less weight than the observations of trained professionals, and they addressed the vocational consultant’s assessment. However, Ms. Petrone’s medical records included multiple reports and Attending Physician Statements from her treating physicians which indicated that Ms. Petrone was severely limited in her functional capacity and was unable to perform any work. The final denial letter mentions some of the treating physicians, but completely ignores and fails to consider the contrary opinions found in the treating physicians’ reports. Further, Johnson & Johnson did not even mention that their own physical therapist performed an FCE and determined that Ms. Petrone was not capable of sedentary work.
The “Rubber Stamp” Method of Disability Claim Review
Instead, Johnson & Johnson relied heavily on the opinion of their hired allegedly independent medical examiner who determined that Ms. Petrone was recovered from her surgery and could return to work with no restrictions or limitations whatsoever. The court determined that there was no explanation for why this one independent medical examiner’s opinion was in such contrast to the opinions of the other multiple physicians who also examined Ms. Petrone and whose opinions ranged from her not being able to work at all, to her being limited to only “light” work. As such, Johnson & Johnson abused its discretion to credit a report with such a bias in favor of rejecting her claim. J&J employed what we often refer to as the “rubber stamp” method of claim handling. The rubber stamp method means and insurance company ignores everything the claimant sends to be reviewed, but what will accept without question whatever the opinion is of their own hired gun doctor.
J&J Ignores the SSDI Approval for Long Term Disability Benefits
Even though a favorable Social Security Administration decision granting disability benefits is not binding on a group long-term disability plan administrator’s decision to grant or deny benefits, it still must be addressed. The Court found that Johnson & Johnson abused its discretion by not addressing the SSA’s decision, especially because the SSA relied on certain medical evidence which Johnson & Johnson also possessed, but also failed to mention in their final denial letter. Additionally, the SSA applied a virtually identical definition of disability as was contained in the Johnson & Johnson plan when making their determination.
Johnson & Johnson also based their denial of disability benefits on a claim that Ms. Petrone failed to cooperate with the evaluation of her claim, which is required under the terms of the Plan. They stated that she failed to put forth her best effort while undergoing the FCE and Independent Medical Examination, which were performed at the request of Johnson & Johnson. While some reports of malingering, self-limiting behavior and exaggeration of symptoms were noted, both physicians also indicated that Ms. Petrone was “cooperative throughout the testing” and that there was no “generalized overreaction.” Additionally, Ms. Petrone provided an expert report rebutting the purported diagnosis of malingering, which the Court found Johnson & Johnson failed to fully consider.
While the Court found that Johnson & Johnson abused its discretion by picking the evidence from the administrative record which favored a denial of benefits and ignoring any evidence to the contrary, the Court also determined that there was also evidence in the administrative record to support that Ms. Petrone did not meet the Plan’s definition of total disability. Therefore, both parties’ motions for summary judgment were denied and the matter was remanded back to Johnson & Johnson to perform a full and fair review of Ms. Petrone’s claim for disability benefits. The fact this claim was remanded is only a partial victory as Johnson and Johnson will now have a second opportunity to review the claim and possibly deny disability benefits again.
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. We handle disability claim nationwide. Our law firm did not represent Ms. Petrone in her disability claim, appeal or lawsuit.