The Plaintiff in Daniel M. Wehner v. Standard Insurance Company (Standard) was an independent financial planner who was insured under a Group Long Term Disability Insurance Policy (Plan). He obtained his policy through the Association for Independent and Franchise Professionals. The Plan was administered by the Standard Insurance Company.
The Plan provided short-term disability (STD) benefits and long-term disability (LTD) benefits for those who were totally or partially disabled from performing the material duties of their own occupation due to a physical disease injury, pregnancy, or mental disorder.
The material duties were defined as “the essential tasks, functions and operations, and the skills, abilities, knowledge, training and experience, generally required by employers from those engaged in a particular occupation that cannot be reasonably modified.”
On August 15, 2016, Plaintiff filed a claim for disability benefits noting he suffered from back, leg, and spine pain in addition to headaches resulting from a hypoxic event. He also had ulcerative colitis. He submitted medical records from five treating physicians. Only one treating doctor submitted an Attending Physician’s Statement in which she opined that Plaintiff’s “ability to function had declined significantly due to uncontrolled pain.” The doctor also reported that Plaintiff could not concentrate and could not sit for more than 15 minutes.
On October 13, 2016, Standard informed Plaintiff it needed more information in order to determine his eligibility for LTD benefits. On December 12, 2016, and again on February 7, 2017, Plaintiff wrote letters to Standard emphasizing he was applying for LTD benefits based on his total disability, not just partial disability. Plaintiff also claimed he became disabled in March 2016.
Standard Evaluated the Medical Reports of Five Treating Physicians:
· Dr. Severyn, a pain management specialist, diagnosed Plaintiff with spinal stenosis of the lumbar region and indicated he suffered from post laminectomy syndrome.
· Dr. Viljoen, a neurosurgeon, discussed with Plaintiff the option of surgery which Plaintiff would think about and consider.
· Dr. Kurpita saw Plaintiff many times through 2015 and 2016 and is the physician who provided the Attending Physician’s Statement. Dr. Kurpita noted that Plaintiff reported severe headaches and prescribed medication. The doctor also noted the medication did not cause side effects and did not interfere with Plaintiff’s ability to perform activities of daily living.
· Doctor Lin, a neurologist, treated Plaintiff for his headaches. The doctor thought the headaches were due to hypoxia suffered by Plaintiff during a recent MRI. The doctor saw Plaintiff several times, and Plaintiff reported that his symptoms stayed the same and did not change from visit to visit.
· Dr. Scholl, gastroenterologist and hepatologist, treated patient for abdominal pain. On May 24, 2016, the doctor noted that Plaintiff was feeling better overall, but his abdominal symptoms worsened his back pain.
Standard Called in Reviewing Physicians to Evaluate the Medical Evidence
Dr. Carlson, a vocational consultant and board-certified physical medicine and rehabilitation specialist, reviewed the medical file. She concluded that Plaintiff did suffer from pain due to his spinal fusions and diagnosis of spondylolisthesis, but that she did not believe he would have been precluded “from sedentary level work in the calendar year 2016.”
Dr. Carlson also reviewed Plaintiff’s Facebook account and found he had posts about “doing significant construction work around his house, as well as participating in hobbies and recreational activities such as fishing.” The doctor continued, “In my opinion, if an individual is precluded from doing sedentary level work, I would not anticipate that he would be able to do these other activities.”
Dr. Carlson also noted that Dr. Kurpita had not put any restrictions on Plaintiff. He could still drive a car and there was no impairment from any cognitive activities.
Based the medical evidence, on February 23, 2017, Standard denied Plaintiff’s claim for LTD benefits. Standard acknowledged that Plaintiff had documented chronic back pain and shoulder pain, but the records did not support a finding of disability. There were no restrictions on his ability to perform his sedentary job.
Plaintiff’s Administrative Appeal
On May 26, 2017, Plaintiff submitted medical records concerning should surgery in December 2016, letters from treating physicians and a functional capacity evaluation. He argued that his constant pain was severe enough to qualify him for total disability.
Plaintiff also argued that his Facebook posts merely showed he was trying to lead a healthy life. Besides, he said the gardening was light work that required no thinking and the construction project was done with the help of his wife and adult son.
Standard reviewed the medical records submitted and letters from treating physicians. Comments were that his headaches “are worsened by staring at computer screen,” or that his headaches “affect his ability to concentrate, make important decision, and create financial plans.”
Plaintiff also submitted a Functional Capacity Evaluation (FCE). The physical therapist who conducted the exam concluded that the plaintiff was “limited in function consistent with lumbar radiculopathy.”
One of Standard’s reviewing physicians found that the medical records well-documented Plaintiff’s suffering from chronic low back pain, but that the pain should not limit his ability to perform the duties of his job. Another one found that although Plaintiff was precluded from working for the twelve weeks following his December 2016 spinal surgery, he could have otherwise performed his job duties. His claim for LTD benefits was denied.
Standard’s Denial of LTD Benefits Was Based on Substantial Evidence and Not Arbitrary and Capricious
On October 24, 2017, Standard denied Plaintiff’s appeal, so he filed this ERISA lawsuit. The Court carefully examined the administrative record and considered Plaintiff’s arguments and concluded that Standard’s decision denying LTD benefits was not arbitrary and capricious. The Court stated its reasons for each issue it resolved:
· Standard’s reliance on opinions of independent reviewing physicians was not arbitrary and capricious when Standard adequately explained its reasons for its decisions and also relied on objective evidence in making its decision.
· Standard did not act arbitrarily and capriciously by ignoring intellectual aspects of Plaintiff’s occupation when Plaintiff never argued that he was cognitively impaired. Plus, the independent reviewing physicians did consider those aspects of the medical records.
· Standard’s reliance on social media was not arbitrary and capricious.
· Standard did not act arbitrarily and capriciously when weighing the FCE because it gave a reasonable explanation for its decision.
· Standard did not “cherry-pick” the medical tests to rely on and explained why it made the choices it did.
The Court concluded that, “In sum, the Defendant did not act arbitrarily and capriciously when it denied Plaintiff disability benefits.”
If you have questions about your own disability claim, contact one of our attorneys at Dell & Schaefer for a free consultation.