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Ortiz Law Firm | National Disability Law Firm
Ortiz Law Firm is dedicated to helping people recover the disability benefits they deserve. We handle group Long Term Disability (LTD) claims, individual disability insurance policy claims, ERISA disability claims, and Social Security Disability claims.
The court ruled that Hartford reasonably relied on medical opinions and surveillance evidence in deeming her ineligible for continued benefits, which means Hartford’s decision to terminate LTD benefits was rationally justified and thus is not arbitrary and capricious.
The judge stated that, "the record, the policy, and the Parties’ arguments do not support the assertion that Plaintiff was disabled as of July 2012 (termination of LTD benefits) and August 2012 (termination of LWOP benefits). The Court, therefore, has no alternative other than to affirm Unum’s decision to deny Plaintiff’s benefits.”
In this case, the court agreed with the district court that Hartford’s decision was reasonable and did not amount to an abuse of discretion. The record readily shows that Griffin received a fair and thorough consideration of his claim and that the available evidence reasonably supported Hartford’s conclusion.
Here, Aetna has engaged in multiple procedural irregularities, including conducting a self-serving paper review of the medical files based on the incorrect disability standard, relying on the opinion of a non-treating, non-examining physician without reason, and denying benefits based on inadequate information and lax investigatory procedures, as evidenced by Aetna’s decision not to pursue an independent medical examination and its failure to analyze the specific requirements of Plaintiffs own occupation. These irregularities compounded each other and lead the Court to find that Aetna acted arbitrarily and capriciously in denying Plaintiffs LTD benefits.
Defendant informed Plaintiff that her claim for LTD benefits was denied because the medical information provided did not support restrictions and limitations and did not demonstrate a functional loss. The plaintiff argued that she was not required to submit objective medical evidence to prove her disability.
Disability benefits were paid for approximately one month and then were terminated. The termination letter acknowledged that “a medical condition may exist” but stated that “there must be objective medical information to support disability benefits” under the Plan. However, the court concluded that the decision to deny Godmar’s claim for short-term disability benefits beginning in July was arbitrary and capricious.
After reviewing the administrative record and giving no deference to Provident’s decision to terminate benefits, the court found substantial evidence supporting Provident’s decision to terminate Gilewski’s long-term disability benefits.
The Court held that Life Insurance considered all relevant information, including Abbey’s treatment notes, treatment notes from Plaintiff’s treaters at Philhaven, and the notes from the board-certified psychiatrist based on his peer review of Plaintiff’s medical records. The Court concluded that in light of the foregoing thorough review and subsequent basis for its denial, Life Insurance’s decision to deny long-term disability benefits to Plaintiff was not without reason and did not meet the required arbitrary and capricious standard. The Court further held that Life Insurance did not engage in any action violating Section 503 of ERISA and that Plaintiff did not have a separate, private cause of action for attorney’s fees and litigation costs.
The Court addressed several issues within the Plan’s determination that the Court found did meet the required arbitrary and capricious standard. (1) Whether the Plan ignored favorable evidence from the Plaintiff’s treating physicians. (2) Whether the Plan conducted a selective review of the evidence from Plaintiff’s treating physicians. (3) Whether the Plan failed to conduct its own physical evaluation of Plaintiff. (4) Whether the Plan relied too heavily on non-treating physician consultants.
The problems in Aetna's review of Maiden's evidence—inexplicably disregarding the opinions of treating physicians and ignoring evidence supporting disability while cherry-picking evidence to support a denial—lend an unmistakable hue of capriciousness to Aetna's review.
The parties’ supplemental briefing clarifies that, as an initial matter, they dispute the applicable policy to Plaintiff’s disability claim. Defendant argues that the Los Alamos National Security, LLC (“LANS”) Group Disability Income Policy (“LANS Policy”) applies to Plaintiff’s disability claim. Plaintiff disagrees and maintains that a University of California (“UC”) Supplemental Disability Policy (“UC Policy”) applies.
In this case, the court ruled that the conclusion by the peer review consultant was without reason when the evidence of record was examined. Thus, defendant acted arbitrarily and capriciously when relying on the peer review report to deny benefits.
Farooq Khan, M.D. (“Khan”), is a neurologist who filed for long-term disability insurance benefits. Provident Life and Accident Insurance Company (“Provident”) denied Dr. Khan’s LTD claim. After exhausting his appeals directly with the insurance company, Dr. Khan filed suit against Provident for breach of contract, asking the court to award payment of his long-term disability benefits. Dr. …
The plaintiff argues that his disability has a physiological cause – in particular, brain damage likely resulting from HIV – and that Prudential should not have applied the mental health limitation. In this case, the Court agreed.
Cara R. Denney (“Denney”) was an employee of Wagner Equipment Company (“Wagner”) where she was a Computer and Technology Instructor. Her job duties “required extensive computer use” and “the ability to instruct employees on the use of various computer systems.” She was also required to travel up to fifty percent of the time, be able to …
Dana Krysztofiak (“Krysztofiak”) works as a registered nurse but was previously a Clinical Coordination Manager for the company HomeCare Maryland, LLC. In 2016, Krysztofiak ceased working because of problems with fibromyalgia and psoriatic arthritis. She then filed for long-term disability benefits with Boston Mutual Life Insurance Co. (“Boston Mutual”). According to the language of the policy: Further, payments only …
The Court found that Prudential abused its discretion in relying upon a vocational assessment that was based only on Prudential’s hired external medical reviewer’s opinions rather than all of the medical evidence.
In Pearson-Rhoads v. Aetna Life Insurance Company, the plaintiff sued for the payment of long-term disability insurance benefits from the insurer of her ERISA governed plan, Aetna Life Insurance Company. The plaintiff made numerous arguments. All were rejected by the court. Of particular note here is the plaintiff’s argument that Aetna abused its discretion by …
In Faciane vs. Sun Life Assurance Company of Canada, the claimant received a monthly benefit for long-term disability benefits pursuant to an ERISA-regulated group insurance policy. The group policy covered employees of Capital One Financial Corporation. He alleged that Sun Life had been underpaying him for years. The material facts of the case were not in …
Colon Carter (“Carter”) worked as an estimating analyst for Bath Iron Works (“BIW”), a subsidiary of General Dynamics. His job duties included “developing cost proposals for new Navy and commercial work; developing and maintaining proposal support documents and checklists; creating financial models; maintaining company baselines for all Programs; assisting management with department staffing plans; and …
The Court concluded that Warner’s motion must be granted because Unum abused its discretion in denying her claim without substantively explaining its rejection of her functional capacity evaluation and relying exclusively on the absence of objective tests confirming her subjective symptoms when denying her claim.
The case Meghan Christmas v. Sun Life Assurance Company of Canada was decided by the U.S. District Court for the District of Connecticut on December 13, 2018. In this case, Meghan Christmas (“Christmas”), a Manager of Global Solutions Integration for ISGN Corporation, sought long-term disability (“LTD”) benefits from Sun Life Assurance Company of Canada (“Sun Life”). Between …
Here, Chernequa Dawson (“Dawson”) worked as a Care Transition Coordination (“CTC”) Nurse Care Manager and was employed by Cigna Corporation (“Cigna”). Through her employment with Cigna, she was covered under both a short-term and long-term disability plan. For these plans, Cigna pays the short-term disability plan benefits, while Life Insurance Company of North America (“LINA”) pays for long-term …
Based upon an exhaustive review of the administrative record, the Court found that the plaintiff had established by a preponderance of the evidence that he was disabled under the terms of the Plan during the relevant period.