Ricky D. Hayes v. Dearborn National Life Insurance Company
This case involves Ricky D. Hayes (“Hayes”) who was employed as an adjuster for F.A. Richards & Associates, Incorporated (“F.A. Richards”). He worked at F.A. Richards from 1999 to 2010 and had coverage under a group insurance long-term disability plan. Dearborn National Life Insurance Company (“Dearborn”) was the underwriter and administrator of the plan. The plan states that an award of long-term disability benefits could be made if the claimant is “continuously unable to perform the Material and Substantial Duties of [his] Regular Occupation” as the result of an injury or sickness. After receiving benefits for a period of twenty-four months in a row, the claimant would then be able to continue benefits if he is “unable to engage in any Gainful Occupation.” However, if the disability “is due to a Mental Disorder of any type,” the claimant may not receive benefits for longer than twenty-four months. In order to extend those benefits any longer, the claimant must have a physical disability that impairs him from executing any gainful employment at all.
Around the fall of 2010, Hayes filed a claim for short-term disability benefits. This claim was the result of anxiety, depression, and sleep disorder. Hayes’ claim was approved for short-term disability benefits, which subsequently resulted in an approval of long-term disability benefits with an effective date of April 2011. When interviewing him for his long-term disability benefits, Dearborn discovered that Hayes had a total hip replacement in October 2008 but had worked for two years after the procedure prior to the claim. Once approved of the long-term disability benefits, Hayes was told that his “primary disabling conditions” were mental disorders, which limited his potential claim to only twenty-four months of payments. This would lead to a termination of payments in April of 2013. Dearborn explained this limitation to Hayes in two different letters in 2012.
Hayes claimed that he was impaired by both mental and physical disabilities. Because of this, Dearborn requested information from Hayes’ doctors in order to determine the validity of this claim. Hayes submitted records from his orthopedist, Dr. Yerger. When he had last seen Hayes, Dr. Yerger said that he could sit for eight hours; stand for four hours; occasionally, frequently, or continuously carry or pick up 10, 50, or 125 pounds; and frequently crawl, reach above his shoulder, balance, kneel, or climb. Dr. Yerger’s notes also stated that Hayes was disabled as the result of “severe anxiety and depression.” Hayes then submitted additional information to Dr. Yerger, explaining that he was fatigued and lacked enough strength in his hip to perform many tasks. Dr. Yerger updated his statement with this information, but also explained that Hayes’ hip was in fine condition and did not need medical treatment or therapy.
Later, Dearborn had an R.N. named Margarey Thompson and a Dr. Miguel Velasquez review Hayes’ records. They were unable to find any physical or objective evidence to support the claim for physical disabilities. Relying on this, Dearborn sent a letter to Hayes explaining that he was limited to the benefits that he had already been paid. The letter further indicated that because Hayes had advised Dearborn that he was receiving Social Security benefits for physical conditions, it would give him an additional thirty days to provide more evidence.
After that time frame passed, Dearborn sent Hayes another letter that explained that his failure to submit any information would result in a closed claim and termination of benefits. At that point, Hayes additionally submitted information from three other mental-health providers. R.N. Thompson and Dr. Velasquez reviewed this information and again found that there were no physical findings that supported an indication of physical ailments. This resulted in Dearborn notifying Hayes that it would be keeping its case closed.
Shortly after, Hayes filed an appeal and submitted more information on his behalf. In April of 2014, Dearborn proposed that Hayes submit to a Functional Capacity Exam at its own expense in order to understand Hayes’ physical condition. Hayes declined and Dearborn instead asked Dr. Tanya Lumpkins to do an independent review of Hayes’ records. She contacted Dr. Yerger and a Dr. Vanderlick to consider their opinions. Dr. Yerger stated that he was not sure that Hayes was physically disabled, though he had not seen the patient in two years so he was unable to comment on that condition. Dr. Lumpkins believed Hayes’ diagnosis of hip pain, fibromyalgia, and chronic fatigue syndrome, stating that he should “avoid working at unprotected heights, driving a company vehicle, working with heavy machinery, or safety sensitive materials,” and be “limited to light-duty levels of physical function in an occupational setting.”
Dearborn then sent the file to Bob Zukowski, a vocational rehabilitation consultant, so that he could analyze Hayes’ level of employability. Zukowski noted that Hayes was unable to execute his own job’s duties, but he provided seven alternate occupations which Hayes would be able to perform. Since Hayes did not have any physical disabilities, Dearborn made a final decision affirming the termination of Hayes’ benefits. Hayes then filed suit. The district court ruled in favor of Dearborn, and Hayes appealed in the immediate court.
Hayes main claim is that Dearborn’s decision denying his claim was not supported by substantial evidence. While Dr. Lumpkins did agree with Hayes’ diagnosis of hip pain, fibromyalgia, and chronic fatigue syndrome, Hayes would only be allowed benefits if those ailments kept him from executing any gainful occupation. Zukowski identified seven different career paths that Hayes would have been able to pursue with his level of skill, training, and education. Because of this, Dearborn decided that Hayes was unable to meet the “any Gainful Occupation” requirement of the plan. As a result, the court found that there was a “rational connection” between Zukowski’s report and the denial of benefits. Therefore, the court ruled in favor of Dearborn and against Hayes, affirming the denial of any further benefits.[Note: this claim was not handled by the Ortiz Law Firm. It is merely summarized here for a better understanding of how Federal Courts are handling long term disability insurance claims.]
Here is a PDF of the case:Hayes v. Dearborn Nat'l Life Ins. Co. 5th Cir