Court: United States District Court for the Western District of Kentucky, Louisville Division
Insurance Carrier: Reliance Standard Life Insurance Company
Claimant’s Employer: Baptist Healthcare System, Inc.
Claimant’s Occupation: Physician
A Physician’s Battle with Severe POTS
Dr. April Halleron, a physician with Baptist Healthcare System in Kentucky, began experiencing debilitating symptoms associated with severe postural orthostatic tachycardia syndrome (POTS), including dizziness, fatigue, joint pain, and episodes of near-syncope. In June 2022, she applied for short-term disability (STD) and long-term disability (LTD) benefits under her employer-sponsored plans administered by Reliance Standard Life Insurance Company.
Although her condition was well documented by her treating cardiologist, Dr. Melissa Perrotta, who stated that Dr. Halleron required rest and long-term work accommodations, Reliance, through its third-party administrator, Matrix Absence Management, denied both claims.
Reliance Denied Both Claims on Technical Grounds
Matrix first denied the STD claim, asserting that Dr. Halleron’s POTS symptoms were related to a pre-existing condition because she had visited a doctor within three months of her coverage start date. Matrix offered no analysis specifically linking that visit (for ADHD!) to POTS and failed to explain how the condition fell within the policy’s exclusion.
Separately, her LTD claim was denied on the basis that there was purportedly no evidence that she was “totally disabled” under the policy’s definition. However, Matrix’s denial letter was sparse, offering only a vague summary of medical records and completely ignoring Dr. Perrotta’s clear medical opinion that Dr. Halleron required disability benefits and long-term accommodations.
Court Finds Serious Procedural Flaws
The court found that Reliance violated ERISA claims procedures in both denials. Specifically, the LTD denial failed to engage in reasoned decision-making as it did not assess whether Dr. Halleron could perform the specific duties of her job or address key medical opinions from her treating physician:
“Because Matrix plainly failed to “rel[y] on medical evidence that assessed [Dr. Halleron’s]
physical ability to perform job-related tasks[,]” the denial was arbitrary and capricious.”
Similarly, the STD denial was also flawed. Reliance failed to establish a meaningful relationship between the alleged pre-existing condition and the disabling condition, offering only a superficial review of Dr. Halleron’s medical history.
A New Chance for a Full and Fair Review
Rather than awarding benefits outright, the court remanded both claims to Reliance for a full and fair review, and instructed the insurer to comply strictly with ERISA’s procedural requirements. The judge noted that while Dr. Halleron provided strong medical support, the record was inconclusive as to whether she clearly qualified for benefits under the terms of the policies.
If your claim for disability benefits has been denied due to procedural errors or for vague reasons, the Ortiz Law Firm is ready to help. We represent doctors and other professionals struggling with complex conditions like POTS, ensuring that their rights are protected under ERISA. Call (888) 321-8131 or contact us online to schedule a free case evaluation today.
Disclaimer: This case was not handled by the Ortiz Law Firm. The court case is summarized here to give readers a better understanding of how Federal Courts decide long-term disability ERISA claims.
Here is a PDF copy of the decision: Halleron vs. Reliance Standard Life Insurance Company
