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Reliance Termination of Benefits Is Upheld When Evidence Was Conflicting

In Karen Gammon v. Reliance Standard Life Insurance Company (Reliance), Plaintiff worked for Cape Cod Hospital for 23 years as a medical transcriptionist when she stopped working due to pain from sciatica. She applied for total long-term disability (LTD) benefits through her employer’s insurance provider, Reliance.

Plaintiff claimed that sitting for more than 20 minutes at a time caused her excruciating low back pain. She also claimed that she took narcotics for pain relief and could not drive. She submitted a statement from her treating physician which supported her claim. Reliance determined that she was unable to perform the material duties of her regular occupation and approved her claim for LTD benefits.

According to the policy, after 36 months of receiving disability benefits, the definition of total disability changed and required the person receiving benefits to prove they were unable to perform the material duties of any occupation. A specific clause of the policy stated that at that time, “We consider the Insured Totally Disabled if due to an Injury or Sickness he or she is capable of only performing the material duties on a part-time basis or part of the material duties on a Full-time basis.”

Plaintiff received LTD benefits from November 2012 to July 28, 2016, when Reliance determined she could work and terminated her benefits. She appealed and when she had exhausted her administrative remedies, she filed this ERISA lawsuit in the U.S. District Court for the District of Massachusetts alleging that Reliance’s termination of her benefits was arbitrary and capricious.

Plaintiff presented several medical opinions supporting her claim. She primarily relied on a report from her consulting physician, Dr. Birbiglia, who examined her on November 29, 2016, and concluded that Plaintiff was unable to sit or stand for 20 minutes, had memory problems likely associated with her pain medications, and had bad migraines that could last up to 20 days at a time. The doctor listed 19 medications Plaintiff was taking. He concluded that, “At this time, in my opinion, she is totally disabled from any gainful employment.”

Reliance commissioned a third-party vendor, Dr. Polanco, board-certified in Occupational Medicine, to review Plaintiff’s medical records. He concluded that she did have some limitations, but that she could work in a “sedentary level of work capacity.”

Reliance also conducted video surveillance over three consecutive days and concluded that Plaintiff’s activities did not support her claims. She was seen driving, shopping, carrying full shopping bags, and leaving her home in the morning and not returning until evening.

Plaintiff’s application for disability benefits through the Social Security Administration was granted. Both sides relied on this approval to support their positions. The Court found the SSDI decision “murky.”

The District Court found it a close call but ruled in favor of Reliance, concluding, “There is evidence in the record to support both the contention that Ms. Gammon is fully disabled physically and that she is not. Under these circumstances, where I review Reliance Standard’s decision under a deferential standard, I will grant Reliance Standard’s motion for summary judgment because its determination, while not inevitable, was based on substantial evidence in the record.”

Plaintiff Objected to the Opinion of Dr. Polanco

Plaintiff alleged that Dr. Polanco failed to review the report of Dr. Birbiglia. The Court disagreed and noted that in Dr. Polanco’s report, he specifically listed Dr. Birbiglia’s report and medical records as ones he had reviewed.

Plaintiff also complained that Reliance and Dr. Polanco ignored Dr. Birbiglia’s medical records from 2018 examinations that she submitted during her administrative appeal.

The Court explained that the issue was whether Reliance properly terminated her benefits in July 2016 and the appeal was in January 2017. Dr. Polanco’s 2018 examinations would not be relevant. Besides, she claimed she submitted them with her appeal which would have been impossible since the appeal was in 2017.

The Video Surveillance

Plaintiff objected to the video surveillance and claimed it did not support Reliance’s termination of her LTD benefits. The video showed:

The Court found that the “surveillance contradicts Ms. Gammon’s asserted limitations.” It also called into question Dr. Birbiglia’s report that she was unable to drive, sit or stand for more than 20 minutes.

The Court noted that the contradictions did not necessarily mean Plaintiff was able to work full-time job, but also noted that “the fact that it contradicts her assertions does not advance her position and adds credibility to Reliance Standard’s position that she is not disabled within the meaning of the policy.”

The Court’s Final Conclusion

The Court noted that its job was not to determine “which side is right.” The Court’s job was to determine if Reliance’s conclusion that the Plaintiff could work was “reasonable and supported by substantial evidence in the record as a whole.”

The Court held that, “the record shows conflicting evidence about Ms. Gammon’s capacity to work. Under an abuse of discretion standard, this type of conflicting record supports summary judgment for Reliance Standard… Reliance Standard’s determination was not inevitable, but it was solidly grounded.” The decision to terminate benefits “is supported by a reasonable reading of the record as a whole.”

This case was not handled by our office, but we believe in can be instructive for those who are appealing the termination of their LTD benefits. If you have questions about this case, or about any aspect of your claim for either short-term disability benefits or LTD benefits, contact one of our attorneys at Dell & Schaefer for a free consultation.

Read more about Reliance Standard disability lawsuits and back pain disability insurance claims. Also see our Q&A section for Disability Company Video Surveillance.

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