Disability Benefit Claims Law Blog

Federal Judge Reverses MetLife's Denial of Disability Benefits

gdell@dnslaw.com (Gregory Dell) — Mon, 18 Jun 2007 14:45:17 -0500

Carolyn Kinser, an employee of Associates First Capital Corporation filed a lawsuit against Met Life for wrongful denial of disability benefits. Ms. Kinser was disabled from her occupation due to bipolar disorder and major depressive order. Ms. Kinser had been under continued care and treatment with the same psychiatrist for more than ten years.

Met Life hired an allegedly independent doctor to review Ms. Kinser’s medical records. After review of Ms. Kinser’s records, the independent doctor advised Met Life that Ms. Kinser’s medical condition was not supported by objective evidence and there was “no documented functional impairment that would preclude plaintiff’s ability to return to work”.

The Federal Judge held that “Met Life was wrong to essentially ignore Dr. Patel’s (Ms. Kinser’s psychiatrist) clearly stated and supported opinion that plaintiff was unable to work in any type of position.” The judge also stated “psychiatric conditions are not easily identifiable by objective measures.” The court also noted that Met Life’s doctor neither examined Ms. Kinser nor spoke with her treating psychiatrist.

Diagnosis of Insured's Medical Condition After Termination of Employment Does Not Preclude Disability Claim

gdell@dnslaw.com (Gregory Dell) — Mon, 18 Jun 2007 14:43:53 -0500

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.

Unum Ordered to Pay Disability Benefits to Attorney Suffering From Sick Building Syndrome

gdell@dnslaw.com (Gregory Dell) — Mon, 18 Jun 2007 14:41:59 -0500

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)

Court Upheld Standard's Decision to Deny Disability Benefits

gdell@dnslaw.com (Gregory Dell) — Mon, 18 Jun 2007 14:38:58 -0500

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.

Prudential's Motion to Dismiss Claimant's Disability Benefits is Denied

gdell@dnslaw.com (Gregory Dell) — Mon, 18 Jun 2007 14:37:32 -0500

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.

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

gdell@dnslaw.com (Gregory Dell) — Mon, 18 Jun 2007 14:02:00 -0500

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.

MetLife Denial Reversed on Appeal: A Diagnosis of Radiculopathy is Exempt from 24 Month Limitation Period for Neuromusculoskeletal Disorders

gdell@dnslaw.com (Gregory Dell) — Fri, 13 Apr 2007 12:58:53 -0500

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.

Hartford's Attempt to Deny Disability Benefits Based on Video Surveillance is Reversed on Appeal

gdell@dnslaw.com (Gregory Dell) — Fri, 13 Apr 2007 12:57:44 -0500

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.

Unum's Denial of Pediatric Nurse is Overturned on Appeal

gdell@dnslaw.com (Gregory Dell) — Fri, 13 Apr 2007 12:54:55 -0500

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.

Hartford Ordered to Pay Disability Benefits

gdell@dnslaw.com (Gregory Dell) — Mon, 05 Feb 2007 12:12:47 -0500

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.

Hartford Ordered to Re-Evaluate Denial of Disability Benefits

gdell@dnslaw.com (Gregory Dell) — Mon, 05 Feb 2007 12:08:25 -0500

James Linnen, a powerhouse operator for Goodyear, Tire and Rubber Company, was insured under his company’s group disability plan issued by Continental Casualty Company. Mr. Linnen began collecting long-term disability benefits for narcolepsy and cataplexy in 2001. In 2004, Hartford Life and Accident Insurance Company purchased Continental and reviewed Mr. Linnen’s disability status. After the treating physician admitted Mr. Linnen was capable of sedentary work, Hartford terminated Mr. Linnen’s benefits in April 2005. Hartford found alternate occupations Mr. Linnen could perform such as cage boss and order parts clerk. Hartford upheld its decision in appeal and Mr. Linnen sued, seeking benefits under the Employee Retirement Income Security Act. (ERISA)

Judge David S. Dowd Jr. of the Northern District of Ohio reviewed Hartford’s decision to terminate benefits and ruled that Hartford used the wrong standard in assessing if Mr. Linnen was entitled to long-term benefits. The policy states the claimant must be unable to “engage in any substantially gainful occupation for which you are, or may reasonably become, qualified by your education, training or experience”. Judge Dowd ruled the term “substantially” alters the definition and Hartford should have assessed whether Mr. Linnen was able to obtain “substantial gainful employment” before terminating benefits. However, if employment is available that pays nearly the same wages and benefits, benefits could possibly be terminated.

James Linnen v. Hartford Life and Accident Insurance Co., No. 05:06CV0141, N.D. Ohio; 2006 U.S. Dist.

Broadspire's Attempt to Deny Disability Benefits After Paying for 10 Years is Denied

gdell@dnslaw.com (Gregory Dell) — Wed, 17 Jan 2007 14:02:20 -0500

Ms. Deborah Donovan, an input shift operator for Eaton Corp, was insured under the company’s self-funded group disability plan. Due to degenerative disk disease, chronic back pain and leg pain, Ms. Donovan filed a claim for total disability benefits in 1993.

After ten years of receiving disability benefits, Eaton terminated payment after an evaluation conducted by Broadspire Services Inc. Broadspire claimed there was no objective medical evidence proving Donovan was unable to work. Ms. Donovan appealed, submitting medical records from her doctor which contained evidence of chronic permanent lumbar radiculopathy and severe lumbar degenerative disk disease. Broadspire upheld its denial of benefits and claimed that Ms. Donavan could perform a sedentary occupation. Additionally, Broadspire claimed that a Functional Capacity Evaluation (FCE) proved that she could work.

After several more denied appeals, Ms. Donovan filed suit seeking reinstatement of benefits under the Employee Retirement Income Security Act (ERISA). Ms. Donovan was granted summary judgment, finding that she was entitled to benefits and Eaton appealed.

On appeal, the court upheld the grant of summary judgment, finding that Eaton’s denial of benefits was an abuse of discretion. After reviewing Donovan’s treating physician’s notes, the court concluded that Eaton’s decision to terminate benefits to a claimant with chronic leg and back pain was unreasonable.

MetLife Ordered to Pay Disability Benefits Beyond 24 Months For a Claimant with Both Mental and Physical Disabilities

gdell@dnslaw.com (Gregory Dell) — Wed, 17 Jan 2007 13:28:52 -0500

Mr. Mark J. Schwartz, an accountant, was insured under his employer’s group disability plan, sponsored by Metropolitan Life Insurance Co. (MetLife), which limits disability benefits for mental illness to 24 months, but to age 65 for a physical disability.

After major heart surgery in 1999, Mr. Schwartz was diagnosed with post bypass anxiety syndrome resulting in elevated blood pressure, dizziness and chest pain. Upon recommendation by his doctor, Mr. Schwartz applied for total disability benefits that year. The application was granted however MetLife concluded the disability was a result of a mental condition, limiting his benefits to 24 months. In 2001, Mr. Schwartz provided additional medical information arguing his disability was physical in nature. After reviewing these records, MetLife’s doctor concluded there were no physical impairments preventing Mr. Schwartz from working. In May 2001, Mr. Schwartz underwent angioplasty and stent surgery. MetLife denied his claim and terminated his benefits in July 2001. Mr. Schwartz sued in U.S. District Court for the District of Arizona seeking reinstatement of benefits under the Employee Retirement Income Security Act (ERISA).

After reviewing the evidence, Judge Mary H. Murguia held that MetLife could have determined Mr. Schwartz’s disability was physical and under estimated the seriousness of Mr. Schwartz’s heart condition. “Plaintiff’s medically documented disability based on a combination of physical and mental impairments warrants the payment of benefits beyond the 24-month period” stated Judge Murguia.

Mark J. Schwartz v. Metropolitan Life Insurance Co., et al., No. CIV-01-2075, D. Ariz.; 2006 U.S. Dist.

U.S. Judge Orders Broadspire to Reinstate a Former Bank Employee's Disability Benefits

gdell@dnslaw.com (Gregory Dell) — Wed, 17 Jan 2007 13:27:33 -0500

Sandra Mikolajczyk, an employee of ABN AMBRO North America Inc., was awarded disability benefits for her depression, fatigue, chronic C6 radiculopathy, carpel tunnel syndrome, cholloid brain cyst, multivalve prolapse, cervical disc surgery, anterior cervical neural decompression and other disorders. Ms. Mikolajczyk was insured by her company’s group disability policy with Broadspire Services, Inc.

After two years of benefits, Broadspire terminated Ms. Mikolajczyk’s coverage. Prior to canceling Ms. Mikolajczyk’s benefits, Broadspire had select documents from her medical record reviewed by Dr. Vaughn Cohen. Dr. Cohen determined that Ms. Mikolajczyk lacked functional impairment that prevented her from working as a bank branch manager. Broadspire physician, Dr. Jamie Wancier, conducted a medical record review and found Ms. Mikolajczyk able to perform full-time sedentary work. Ms. Mikolajczyk promptly filed suit seeking benefits under the Employee Retirement Income Security Act (ERISA).

Judge Katz of the Northern District of Ohio stated that Broadspire “relied on document reviews that were incomplete and went against the weight of the administrative evidence”. Judge Katz further noted that “Broadspire’s refusal to conduct a physical examination, even when tests were recommended by its own reviewing physician, is another factor that weighs against the reasonableness of defendant’s denial of benefits.” Lastly, the court held that Broadspire should have considered the favorable award of social security disability benefits. Broadspire was ordered to pay disability benefits. Opinion available at Sandra Mikolajczyk v. Broadspire Services Inc., No. 3:05-CV-7039, N.D. Ohio.

US District Judge Rules for Disability Claimant

gdell@dnslaw.com (Gregory Dell) — Mon, 15 Jan 2007 10:06:32 -0500

June 23, 2006, U.S. District Judge Joe B. McDade of the Central District of Illinois Ruled in favor of Susan Svejda, an employee of Mercantile Bancorp. Ms. Svedja was employed with Mercantile until 2002. After several visits to physicians and her neurologist, Dr. Douglas Sullivant, M.D., Ms. Svedja was diagnosed with MS, Chronic imbalance, depression and bowel problems including IBS (Irritable Bowel Syndrome) which require her to frequently rush to the bathroom, often times not making it due to other infirmities. As a result of these conditions, Ms. Svedja stopped working and applied for long-term disability benefits from Mercantile’s insurance contract with Continental.

Continental had Ms. Svedja’s medical records reviewed by their physician, Dr. Eugene Truchelet, who concluded there was not enough information regarding Svedja’s bowel problems to conclude whether she merits long term disability benefits, however she would require some workplace limitations including being close to a restroom.

An investigation ensued, and Ms. Svedja’s physical demands at the office were examined. The conclusion was that Ms. Svedja required to be placed in close proximity to a restroom due to her bowel complications. Mercantile claimed it was not feasible to move Svedja’s desk to accommodate her. Mercantile subsequently denied Svedja’s claim and she promptly filed suit seeking benefits under the Employee Retirement Income Security Act (ERISA).

Judge McDade stated that Continental’s denial of Ms. Svedja’s claim was unreasonable under an arbitrary and capricious standard of review. Judge McDade stated Continental “chose to completely ignore the unfavorable information that Mercantile submitted about not being able to move Ms. Svedja’s desk close to a restroom, which would allow her to continue to work,” and “failed to provide a specific reason for denial of benefits when they ignored doctors’ opinions.”

Judge McDade found that Ms. Svedja is entitled to benefits under the disability policy. Susan Svejda v. Mercantile Bancorp Inc., et al., No. 04-1263, C.C. Ill.

California Federal Court Rejects Prudential's Attempt to Limit Claim

gdell@dnslaw.com (Gregory Dell) — Mon, 15 Jan 2007 10:05:05 -0500

Rosa Wood had carpel tunnel syndrome and left work in 1999 because of it. After receiving short term disability benefits and undergoing back surgery, Ms. Wood applied for long term benefits. Initially, Ms. Wood’s claim for benefits was denied however her plan eventually agreed to pay benefits for the first phase of long term disability. Under the first phase, claimants are entitled to benefits for seven to twenty-nine months based on their ability to perform any substantial gainful work. Prudential then denied long-term disability benefits to Ms. Wood during the second phase which would continue benefits beyond the twenty-nine months. After two internal appeals, Ms. Wood sued Prudential in Federal Court.

The court ruled that any “reasonable trier of fact would find Wood to be disabled” and rejected Prudential’s attempt to limit the claim. The judgment was based on evidence stating no factual dispute that Ms. Wood was diagnosed with carpal tunnel syndrome in 1999 and that she had spinal surgery in 2000 and continues to suffer from pain and numbness in her hands. Reports from all of Ms. Wood’s examining physicians support her disability claim with the exception of Dr. Teital who examined Ms. Wood at the request of Prudential. Dr. Teital did not find that Ms. Wood was exaggerating her symptoms.

Additionally, Prudential’s consulting physician, Dr. Ito, did not examine Ms. Wood nor did he dispute Ms. Wood’s diagnosis or the findings of pain from her other doctors. However, Dr. Ito apparently discounted Ms. Wood’s pain limitations on the basis that they were not supported by objective testing. Prudential’s policy did not require the type of testing Dr. Ito required supporting Ms. Wood’s limitations.

Further, Sandra Richter, a vocational counselor who met with Ms. Woods during her first phase of long term disability benefits, concluded that she is totally disabled. Two other vocational reports were written without meeting Ms. Wood and submitted during the evaluation of second phase LTD benefits. These reports were prepared based on limitations that did not include limitations of her use of extremities. Neither of these reports included analysis of the “gainful employment” language of Prudential’s policy which explained that “gainful occupation” is defined as an occupation that provides at least sixty percent of pre-disability earnings. Prudential must now pay all past due long-term disability benefits to Ms. Wood and re-calculate her claim for the future.

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

gdell@dnslaw.com (Gregory Dell) — Fri, 12 Jan 2007 16:35:39 -0500

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.

MetLife's Attempts to Stop Paying Total Disability Benefits After Paying Claimant for 10 Years is Denied

gdell@dnslaw.com (Gregory Dell) — Fri, 12 Jan 2007 15:09:00 -0500

Robert Clarke, a market sales manager for Allstate Insurance Company, stopped working in 1992 due to lumbar spinal stenosis, claiming he was unable to sit, stand, or walk for more than 10 minutes. Mr. Clarke was insured under his company’s group disability plan administered by Metropolitan Life Insurance Co. and was paid total disability benefits as of 1992. After several back fusion surgeries in 1990, 1992, and 1994, MetLife approved Mr. Clarke’s initial claim for benefits. In 2202, after paying total disability benefits for more than 10 years, MetLife decided to terminate Mr. Clarke’s disability benefits and claim that Mr. Clarke could perform sedentary work.

In June 2000, MetLife began video surveillance of Mr. Clarke. The video tapes were reviewed by MetLife’s doctors including an occupational therapist and functional capacity evaluation coordinator. In May 2002, MetLife terminated Mr. Clarke’s disability benefits stating Mr. Clarke’s restrictions and limitations are inconsistent with the video surveillance and medical records. MetLife upheld its decision on appeal and Mr. Clarke sued in the U.S. District Court for the Southern district of Ohio, for reinstatement of benefits under the Employee Retirement Income Security Act (ERISA).

After reviewing MetLife’s denial of disability benefits, Judge Michael R. Barrett stated that MetLife’s reliance on videotaped surveillance in its decision to terminate Mr. Clarke’s benefits was arbitrary. “MetLife’s assertion that plaintiff’s misrepresentation of his functional limitations somehow invalidated objective medical evidence is unreasonable” ruled Judge Barrett. MetLife was ordered to pay back-benefits to Mr. Clarke and reinstate his disability benefits.

Robert B. Clarke v. Metropolitan Life Insurance Co., et al., No. 1:04-cv458, S.D. Ohio; 2006 U.S. Dist.