In Tisha Entz v. Standard Insurance Company, Plaintiff Entz was a classroom teacher in Victorville, California from 1997 until she became too ill to work following the end of the 2014-2015 school year on June 10, 2015. She applied for her disability insurance benefit provided by her employer. She alleged in her claim for disability insurance benefits that her first day off work should be August 14, 2015, the day teachers were required to return to work, which made this her first day of missed work.
Plaintiff had an extensive medical history including heart surgery in 1997, donation of a kidney to her father that same year, spinal discectomy in 2007, and various biopsies over the years. Her main complaints, leading to the claim for disability, began in late 2013. She began feeling ill and weak. She reported to her doctors, “fatigue, headaches, muscle cramping, night sweats, palpitations, and rash.” She told her doctor she had done some research and thought she had Lyme disease.
Between late 2013 and the time she filed a claim for disability insurance benefits in September 2015, she saw her primary care physician and many specialists. At one point, she was being treated by nine different doctors. An orthopedist said she could not work due to pain in her spine.
Her primary care doctor, Dr. Harris, sent Standard a statement on September 9, 2015, saying Plaintiff had a primary diagnosis of Lyme disease with a secondary diagnosis of Bartonella. Dr. Harris also listed diagnoses of Babesia, arthritis, headaches, abdominal pain, diarrhea, nausea, and other gastrointestinal issues.
Dr. Harris stated, Plaintiff’s “physical, mental, and cognitive limitations and work activity limitations” were “due to muscle and joint pain, headaches, gastrointestinal issues” and opined “she is unable to function at work. Needs to remain out.”
On October 16, 2015, a Standard representative interviewed Plaintiff. The representative asked Plaintiff to send Standard her medical records from all physicians who had treated her including test results. Standard ordered medical records, but asked only for those from Jun 1, 2014 to October 26, 2015.
A vocational analysis conducted by a Standard employee found Plaintiff could do “a light duty occupation.” Standard commissioned a paper review by a doctor who noted that while Plaintiff had “multiple somatic complaints” there was “no diagnoses that establish any clear etiology” and no disease process that should limit her work other than an “arthritic knee.”
On January 12, 2016, Standard sent Plaintiff a letter informing her it had denied her claim. The letter informed her she could appeal the denial, but it did not tell her that there were any contractual limitations. She filed an appeal including 150 pages of documents. She added a lengthy letter.
Standard had an outside physician vendor review Plaintiff’s medical records, asking him to evaluate the diagnosis and treatment of Lyme disease and to evaluate whether Plaintiff’s symptoms were supported by the medical evidence. On October 11, 2016, Standard again denied Plaintiff’s claim and said she had not supported her claim with medical evidence and that “chronic Lyme disease is not an evidence based Sickness/illness” and Standard did not accept that as a valid diagnosis.
Plaintiff then filed this ERISA lawsuit in the United States District Court for the Central District of California. The Court agreed with Plaintiff and ordered Standard to pay her total disability benefits for 24 months as required by her policy.
The Lawsuit was Timely Filed
Standard asked the Court to dismiss the case as untimely. According to the policy language, a lawsuit was required to be filed within three-years of the time “proof of loss is required to be furnished.” Standard argued that Plaintiff missed the deadline.
The Court pointed out that this was a case of apparently an ongoing disability, which changed the proof of loss date to 90 days after the end of the period for which the provider is allegedly liable. Applying that law, the three-year limitations period would expire on November 12, 2020. Since Plaintiff filed her lawsuit in March of 2019, her suit was not time-barred.
In addition, the Court found that Standard did not inform her of the application of the limitation period which was a breach of its fiduciary duty. This breach would not trigger the running of the limitations period. So, under this standard alone, the lawsuit would be considered timely.
Plaintiff Met Her Burden of Proving By a Preponderance of the Evidence That She was Totally Disabled
The Court noted that Standard’s review of Plaintiff’s claim, both initially and on appeal, “focused narrowly on discrediting Dr. Harris [Plaintiff’s primary care physician] as a quack, and casting doubt on Plaintiff’s reports that she had Lyme disease.” Standard’s doctor admitted Plaintiff had a number of “somatic complaints” but opined that “no objective identifiable disease process” limited her work. He “did not credibly opine on whether she could ‘with reasonable continuity’ perform the ‘Substantial and Material Acts’ necessary to being an elementary school teacher.’”
The Court gave “greater weight to the opinions of Plaintiff’s multiple treating physicians, each of whom witnessed and assessed her condition over a significant period of time.” The Court also commented that “Disability should have been measured by Plaintiffs functional capacity, given her symptoms, compared to her duties as a teacher…. Plaintiff’s primary treating physicians opined more often and more directly on her inability to work in any capacity. They relied on both their objective observations of Plaintiff’s comfort level as well as her own subjective reports.”
Ultimately, the Court concluded that, “Plaintiff has adequately established she was “totally disabled” under the terms of the Plan for the 24-month period. Accordingly, the Court REVERSES Standard’s decision to deny Plaintiff’s LTD benefits for the 24-month period and AWARDS Plaintiff $51,511.73 in disability benefits owed.”
This case was not handled by our office, but we believe it can be instructive to those struggling to obtain disability benefits from an insurance company that is searching for ways to issue a disability insurance claim denial. For more information about this case, or for assistance with your own claim, even if you have received a denied disability claim from your insurance company, and no matter where you live across the nation, contact us at Dell & Schaefer for a free consultation.