An Indiana Federal Judge recently ruled partially in favor of a claimant who was denied Long Term Disability (LTD) benefits by Sun Life. In the December 2012 ruling in the ERISA Disability Lawsuit, the Court found that Sun Life needed to review and properly address the medical opinion of one of the claimant’s treating physicians. This physician’s review and opinion were in stark contrast to the final opinion and decision of Sun Life. As such, the Court’s decision still leaves hope that the claimant will be able to receive long term disability benefits.
Medical History and the LTD Claim
The claimant previously worked as a Sales Specialist at Teachers Credit Union. As an employee of Teachers Credit Union, the claimant was provided coverage under both a short term and a long term disability plan. After a long history of epilepsy, the claimant began experiencing an increased frequency of seizures in May 2009. A few months later in July 2009, the claimant suffered a seizure while driving which resulted in a car accident. After this incident, the claimant did not return to work.
The claimant applied for and received short-term disability benefits from her employer. However, when she applied for long-term disability benefits with Sun Life, she was denied. In its first decision to deny benefits, Sun Life reviewed the medical records and opinions of the claimant’s treating physicians. To justify its position to deny benefits, Sun Life noted that an Attending Physician’s Statement completed by one of her physicians did not restrict the claimant from walking, standing, bending, sitting, etc. Using this lack of restrictions, Sun Life concluded that the claimant could perform the duties of her occupation. The Claimant Appealed.
In the Claimant’s appeal of Sun Life’s initial decision to deny benefits, the claimant submitted additional evidence which included a vocational report by another treating physician, Dr. Blankenship. In his report, Dr. Blankenship noted that walking, sitting, standing, bending, etc., were not the issues. The issue was the inability to predict seizures and the issues related to having a seizure. Dr. Blankenship concluded that the claimant would not be a reliable worker. Furthermore, Dr. Blankenship noted that the claimant experienced difficulty with memory and word finding. Dr. Blankenship concluded that this would prevent the claimant from performing her prior occupation.
Sun Life was unmoved. In a letter dated November 16, 2010, Sun Life again denied the claim for long term disability benefits. In this letter, Sun Life stated that it had reviewed and considered the newly submitted evidence. Furthermore, Sun Life stated that it had an independent records review conducted by an additional physician. This physician concluded that the claimant was capable of full-time work. This report was then submitted to a vocational consultant who determined that the claimant could perform the material duties of her prior occupation. With this information, Sun Life again denied her claim.
ERISA Lawsuit Filed
With her administrative remedies exhausted, the claimant’s only avenue for benefits was an ERISA disability lawsuit. In her complaint, the claimant contended that Sun Life’s decision was arbitrary and capricious because Sun Life failed to consider and discuss the report of her vocational expert, Dr. Blankenship.
The Court agreed. While the Court noted that Sun Life did not need to address every piece of evidence that was contained in the claimant’s medical records, it should have, however, addressed Dr. Blankenship’s relevant and contrary report. Sun Life had failed to mention the report in its denial letter. Furthermore, Sun Life’s independent medical reviewer and vocational expert each failed to even mention Dr. Blankenship’s contrary opinion.
The Court noted that the “focus of the arbitrary and capricious standard is to ensure that the plan administrator’s reasons for denial ‘meet ERISA’s requirement that specific and understandable reasons for a denial be communicated to the claimant.'” The Court continued that “(e)ven when records are based on subjective complaints, Defendant must still explain the reasons for dismissing those complaints.” The Court concluded that because Sun Life “failed to address Dr. Blankenship’s relevant and contrary report, Defendant’s decision is arbitrary and capricious.”
Unfortunately for the claimant, the Court did not conclude that Dr. Blankenship’s report required that Sun Life find her to be disabled. The Court merely ruled that Sun Life must “address and explain why it accepts or rejects the report in light of the evidence in this case.” So while the claimant might have won a battle, she still might ultimately lose the war.
Although our firm did not handle this case, we handle many like it throughout the country. Please contact us, the disability attorneys at Attorneys Dell & Schaefer , Chartered, for a free consultation and to discuss your disability claim.
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