Disability Benefits Lawyer & Attorney : Dell & Schaefer : Disability Insurance Claims Law Blog

Daniel J. Rochow, the former president of Arthur J. Gallagher & Co., was insured under Life Insurance Co. of North America’s disability plan. The Sixth Circuit affirmed that a disability insurer’s denial of benefits to a former employee who was terminated because his symptoms prevented him from performing his duties was arbitrary and capricious, even though the employee’s diagnosis was not made until after he stopped working.

Daniel Rochow began to experience short term memory loss and was demoted from President to a sales executive. Rochow was diagnosed with a rare form of herpes which causes brain trauma. Rochow sought long-term disability benefits through Gallagher’s Group Insurance Plan, which was administered by Life Insurance Company of North America (LINA). LINA contended that Rochow’s inability to function did not occur until his hospitalization after he stopped working. 

Rochow challenged LINA’s denial of benefits under the Employee Retirement Income Security Act and the District court ruled that LINA’s denial was arbitrary and capricious. The Sixth Circuit affirmed, concluding that Rochow presented sufficient evidence to establish that he was disabled before he stopped working within the meaning of the plan.

Daniel J. Rochow v. Life Insurance Co. of North America, No. 05-2100, 6^th Cir.; 2007 U.S. App. LEXIS 7599.

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Pamela A. Ray, an attorney, was insured under a UNUM disability policy. A Denver trial court ruled recently ruled in her favor that working in a large office building was a material duty of a disability claimant’s occupation as an attorney specializing in major real estate, oil and gas and mining transactions. The court determined that UNUM Life insurance Company of America’s denial of benefits was arbitrary and capricious.

On appeal the 10^th Circuit reversed and remanded with instructions for the District Court to apply the de novo standard of review and to consider new evidence. In affirming the Circuit court ruled that the District court did not err in finding that working in a large office building environment was material duty of the plaintiff’s occupation. The majority noted that working from home was not an effective alternative and that her practice was not easily transferable to another firm. Even if the plaintiff could find equivalent work it would most likely be located in a large office building environment, therefore she is totally disabled.

Pamela A. Ray v. UNUM Life Insurance Company of America, Nos. 05-1284, 05-1420, 10^th Cir,; 2007 U.S. App. LEXIS 7234)

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Carol Shepherd, a fork-lift operator for Daramic, was insured under the company’s group disability plan with Reliance Standard Life Insurance Company. In 2004, Ms. Shepherd had an anxiety attack at work and Daramic suspended her and required that she participate in anger management before returning to work. During her suspension, Ms. Shepherd was receiving treatment at Owensboro Medical Health System Outpatient Counseling Center where she was diagnosed with major depression and anxiety disorder.

Prior to her suspension, Ms. Shepherd worked the swing shift but when it was time to return to work she requested the day shift because her treating physician believed the sleep disturbances would aggravate her psychological conditions. When Daramic refused to give Ms. Shepherd the day shift her doctor said she could not return to work and Ms. Shepherd applied for long-term disability benefits.

Reliance denied Ms. Shepherd’s claim stating that she is not totally disabled and had their own reviewing psychiatrist evaluate her medical records. Reliance upheld its denial of benefits on appeal and Ms. Shepherd sued, seeking benefits under the Employee Retirement Income Security Act (ERISA).

After reviewing the case, U.S. Judge Joseph H. McKinley Jr. of the Western District of Kentucky found that Reliance’s decision to deny benefits was reasonably supported by Ms. Shepherd’s medical record. The judge rejected Ms. Shepherd’s claim that Reliance failed to conduct a personal psychological evaluation since the company’s psychiatrist “thoroughly reviewed Ms. Shepherd’s medical record and relied on the evidence therein to form his opinion.” Judge McKinley found that there was no competent medical proof in the record to support a disability claim.

Carol Shepherd v. Reliance Standard Life Insurance Co., No. 4:06CV-83, W.D. Ky.; 2007 U.S. Dist.

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Jenny Eberle, an employee of Purdue University, was initially approved for long-term disability benefits by the Prudential Insurance Company of America. Shortly after her claim was approved, a new claims examiner and registered nurse reviewed Ms. Eberle’s medical records and decided to terminate her long term benefits in November 2004.

In May 2005, Ms. Eberle sued Prudential alleging breach of contract and breach of the covenant of good faith and fair dealing. Prudential filed a summary judgment motion claiming Ms. Eberle failed to provide objective proof of her disability. Ms. Eberle had four treating physicians that stated she was disabled and could not work. Prudential hired two Registered Nurses and one doctor, which opined that Ms. Eberle’s disease did not prevent her from performing her pre-disability occupational duties. Judge Rudy Lorenzo found that Ms. Eberle satisfied her burden under the policy of providing Prudential with objective medical evidence of her disability but there was a discrepancy as to whether Ms. Eberle’s diabetic complications render her totally disabled from her occupation. The policy defined total disability as ‘unable to perform all of the material and substantial duties of his or her occupation on an Active Employment basis because of an Injury or Sickness”. Judge Lorenzo found that a “genuine issue of material fact as to whether Ms. Eberle was ‘disabled’ as defined by the policy.” Prudential’s motion for summery judgment was denied.

Jenny Eberle v. The Prudential Ins. Co. of America, No. 4:05-cv-0030, N.D. Ind., Lafayette Div.; 2007 U.S. Dist.

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Insured Denied Benefits by Unum Due to Failure to Receive “Appropriate Care”

Larry Mack claimed that he is totally disabled from his occupation as a marriage and family therapist due to diabetes. He sued his disability insurer, Unum Life Insurance Company, after being denied his claim for long-term disability benefits. Unum argued that Mr. Mack is not entitled to long-term benefits because he did not receive “appropriate care” as required by his policy. Mr. Mack admitted to not seeking help from his internal medicine doctor for long periods of time but argued that during these months he was “self-treating” his diabetes by taking Glucophage daily and by monitoring his diet.

The court said such “self-treatment” does not meet the policy requirement that the claimant be under medical treatment in order to receive benefits. The court reasoned that Mr. Mack failed to abide by the standard of care his internal medicine doctor prescribed for diabetic patients, U.S. Judge Linnea R. Johnson granted partial summary judgment to Unum.

Larry B. Mack v. Unum Life Insurance Company of America, No. 06-80308, S.D. Fla.; 2007 U.S. Dist.

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Kelly Iley, a pharmacist for Kroger Co, was insured under the company’s group long-term disability policy with Metropolitan Life Insurance Company (MetLife). In June 2001, Ms. Iley was diagnosed with lumbar disc disease.

Ms. Iley stopped working in May 2001 and had a discetomy in July 2001 and a fusion surgery in May 2002. She continued to suffer from back pain and filed a total disability benefits claim in November 2001. MetLife initially approved Ms. Iley’s claim but terminated benefits in July 2004, noting the plan’s 24 month limitation period for neuromusculoskeletal and soft-tissue disorders. On appeal, Ms. Iley’s treating physicians submitted statements that she was totally disabled due to radiculopathies. MetLife upheld its denial of benefits and Ms. Iley filed suit in the U.S. District Court for the Eastern District of Michigan, seeking reinstatement of benefits under the Employee Retirement Income Security Act (ERISA).

Upon reviewing the case, Judge Sean F. Cox found that MetLife ignored Ms. Iley’s treating doctor’s diagnosis of radiculopathy and wrongly denied long-term disability benefits under ERISA. Judge Cox found that the plan’s 24 month limitation period did not apply to Ms. Iley and ordered reinstatement of her benefits. The court also awarded Ms. Iley over $20,000 in attorney fees.

Kelly Iley v. Metropolitan Life Insurance Co., et al., No. 2:05-cv-71237, E.D. Mich.; 2007 U.S. Dist.

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Robin Plummer, a pharmacist for Kmart Corporation, was insured under the company’s group disability plan administered by Continental Insurance Company. In 2003, Hartford Life Insurance Company took over administration of the plan.

Ms. Plummer’s back problems began in 1998 and resulted in anterior and posterior fusion surgery. In 1999, Ms. Plummer began receiving long –term disability benefits. In 2004, Hartford had Dr. Klein examine Ms. Plummer who concluded that she could perform a sedentary job. Shortly after the evaluation, Hartford sent Dr. Klein video surveillance of Ms. Plummer which showed her driving for 30 minutes, shopping in a department store, and carrying her grandchild. After viewing the surveillance tapes, Dr. Klein issued an addendum to his report stating that Ms. Plummer could perform light-duty work and lift up to 25 pounds. Based on Dr. Klein’s report, Hartford terminated Ms. Plummer’s benefits. Ms. Plummer filed suit seeking benefits under the Employee Retirement Income Security Act.

U.S. Judge Thomas M. Rose of the Southern District of Ohio found that Hartford’s termination of benefits to a claimant with chronic back pain was unreasonable. Judge Rose held that the record supports that Ms. Plummer was unable to return to her job as a pharmacist. The judge said that Dr. Klein’s independent medical exam was flawed since he “initially examined Plummer and determined that she was in the sedentary job classification and then changed his opinion based totally upon videos which included observance of Plummer for a total of approximately 13 minutes.” Furthermore, Judge Rose noted that despite the activities in the video surveillance, Hartford’s doctor could not determine if Ms. Plummer “was experiencing pain”. Summary judgment was granted to Ms. Plummer finding that she was entitled to disability benefits under her plan.

Robin Plummer v. The Hartford Life Insurance Co., No. 3:06cv00094, S.D. Ohio; 2007 U.S. Dist.

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Nancy Mikrut, a pediatric nurse practitioner for Danbury Health Systems, was insured under the company’s group disability plan administered by Unum Life Insurance Company of America. In 1999, Ms. Mikrut was injured in an automobile accident and was unable to return to work due to severe back pain. In January 2000, Ms. Mikrut was diagnosed with spinal stenosis and filed for long-term disability benefits. After an intradiscal electrothermal therapy, Ms. Mikrut has a second surgery in March 2001.

After 24 months of benefits, Unum re-evaluated Ms. Mikrut’s claim. Without meeting her, a Unum medical consultant found Ms. Mikrut capable of full-time sedentary work. In August 2002, Ms. Mikrut’s treating physician told Unum that she was disabled from any occupation in which she had to bend, lift, pull, sit, or stand for periods of time. Unum terminated Ms. Mikrut’s benefits and she filed suit, seeking benefits under the Employee Retirement Income Security Act.

U.S. Judge Stefan R. Underhill of the District of Connecticut found that Unum failed to account for subjective complaints of pain and the treating physician’s opinions before terminating Ms. Mikrut’s benefits. The judge ruled that Unum did not adequately consider an award of benefits by the Social Security Administration. Judge Underhill held that Ms. Mikrut is eligible for continued long-term disability benefits under the plan since she is unable to perform the duties of any gainful occupation. While Unum is not required to credit treating physician’s opinion over other evidence, Judge Underhill stated that Unum cannot “arbitrarily refuse to credit a claimant’s reliable evidence, including the opinions of treating physicians.”

Nancy P. Mikrut v. Unum Life Insurance Company of America, No. 3:03cv1714, D. Conn.; 2006 U.S. Dist.

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Donald Holman, a maintenance technician for Tyson Foods Inc., was insured under Tyson’s group disability plan with Hartford Life and Accident Insurance Co. In April, 2001, Mr. Holman began experiencing headaches and blurred vision. After a cranial MRI, Mr. Holman’s neurologist diagnosed him with a Chiari malformation. Mr. Holman’s neurologist stated he was disabled and Mr. Holman stopped working and filed a claim for long-term benefits. Hartford consulted their doctor who further confirmed Mr. Holman’s disability stating activities such as lifting, pushing, and pulling could cause further complications in Mr. Holman’s condition. Hartford initially approved Mr. Holman’s claim for benefits but later found he was not totally disabled and terminated benefits. Mr. Holman filed suit in the U.S. District Court for the Western District of Arkansas, seeking reinstatement of benefits under the Employee Retirement Income Security Act.

Judge Jimm Larry Hendren ruled that terminating benefits to a claimant suffering from a rare neurological condition was an abuse of discretion. Judge Hendren said Hartford had objective medical evidence of Mr. Holman’s condition and disregarded the opinion of his treating physicians. “Hartford’s failure was based on an almost total failure to investigate Holman’s claims” stated Judge Hendren and found Mr. Holman entitled to long-term disability benefits.

Donald Holman v. Hartford Life and Accident Insurance Co., No. 04-5305, W.D. Ark.; 2006 U.S. Dist.

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