Posted on June 18, 2007 by Gregory Dell

Court Upheld Standard's Decision to Deny Disability Benefits

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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Posted on June 18, 2007 by Gregory Dell

Insured Denied Benefits by Unum Due to Failure to Receive "Appropriate Care"

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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Posted on January 12, 2007 by Gregory Dell

Federal Court Rules that Degenerative Arthritis of Claimant's Knee was a "Sickness" and Not Caused by an "Injury"

Lawrence Levy, M.D., insured under two disability policies with Minnesota Life Insurance Co., became disabled in March 1996 and has been receiving total disability benefits due to osteoarthritis in his right knee. Dr. Levy claims his disability is an “injury” rather than a “sickness” because the osteoarthritis is due to a basketball injury. The policy provides disability benefits to the age of 65 if the disability is caused by “sickness”, disability benefits will be paid for life is the disability is caused by an “injury”.

U.S. Magistrate Judge Sidney I. Schnekier said the best interpretation of the policy is the term “immediate cause”. Under the immediate cause standard, Dr. Levy’s disability is due to sickness. The Judge stated the knee pain is due to degenerative arthritis and should characterize as a “sickness” under the long-term disability policy. Dr. Levy’s benefits will terminate at age 65.

Lawrence B. Levy, M.D. v. Minnesota Life Insurance Co., No. 03-C-5141, N.D. Ill.; 2006 U.S. Dist.

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