Case Summary Provides Insight on How the Courts Reach a Decision on Long-Term Disability Claims

Disclaimer: This was not a case handled by disability attorney Nick A. Ortiz. The court case is summarized here to give readers a better understanding of how Federal Courts decide long term disability ERISA claims.

Case Name: Killen v. Reliance Standard Life Insurance Company

Court: United States Court of Appeals for the Fifth Circuit, Appeal from the United States District Court for the Northern District of Texas

Type of Claim: Long Term Disability.

Insurance Company: Reliance Standard Life Insurance Company (“Reliance Standard”).

Claimant’s Employer:  Covenant Health Systems (“Covenant”).

Disabilities:  neck, shoulder, and upper back pain.

Benefits Paid? Long Term Disability benefits were initially approved and then cut-off or terminated after two years when the definition of “totally disabled” changed such that the claimant had to prove she is incapable of performing the material duties of any occupation for which she is qualified by way of education, training, or experience

Issues: The central issue raised in this cause of action is whether Reliance Standard abused its discretion in denying the claimant’s long-term disability benefits after two years.

Holding: The Court affirmed the district court’s decision granting summary judgment to Reliance Standard on the ground that it did not abuse its discretion in denying the claimant’s long-term disability benefits. In other words, the Court ruled in favor of the insurance company.

Summary: The Court held that there was substantial evidence to support Reliance Standard’s decision to deny long-term disability benefits to the Plaintiff:

[The Plaintiff] Killen first challenges the district court’s finding that substantial evidence supported the plan’s denial of benefits. Substantial evidence is “more than a scintilla, less than a preponderance, and is such relevant evidence as a reasonable mind might accept as adequate to support a conclusion.” Id. (internal quotation marks and citation omitted). Killen claims that the Plan language requires Reliance Standard to show that she can perform all of the job duties of a sedentary vocation on a full-time basis before discontinuing benefits. While it might have shown she could perform sedentary work, she argues, Reliance Standard never showed she could do so full time. Additionally, she claims the district court misconstrued the medical evidence and ignored objective documentation of her pain.

“[M]ost disputed claims for disability insurance benefits are awash in a sea of medical evidence, often of contradictory nature,” 10A Couch on Ins. § 147:33, and this case is no different. Indeed, counsel for Killen admitted as much at oral argument. Courts frequently hear cases, like this one, where the plaintiff’s own treating physicians generally support a finding of disability and the defendant’s vocational specialists and independent medical examiners disagree.

In Holland, for example, a former paper machine specialist who had experienced a heart attack sought long-term disability benefits. See 576 F.3d at 243. The Plan’s language closely tracked the applicable language in this case. See id. at 244. The employee’s primary care physician equivocated, but supported a finding of total disability, and a specialist’s statements about his health were ambiguous: the specialist noted that the plaintiff had serious airway damage, but was improving. Id. The administrator had a third and fourth doctor conduct a paper review of the medical records, and a fifth doctor conducted a physical examination: all three agreed that the employee was not totally disabled. See id. at 244–45. The administrator never consulted a vocational expert. Id. at 249. The internal claim for benefits was denied twice. This court held that there had been no abuse of discretion; the existence of contradictory evidence, the court noted, “does not . . . make the administrator’s decision arbitrary. Indeed, the job of weighing valid, conflicting professional medical opinions is not the job of the courts; that job has been given to the administrators of ERISA plans.” Id. at 250 (internal quotation marks and citation omitted); accord Wade v. Hewlett-Packard Dev. Co., 493 F.3d 533, 540–41 (5th Cir. 2007), abrogated on other grounds by Hardt v. Reliance Standard Life Ins. Co., 560 U.S. 242 (2010) (upholding a denial of benefits where plaintiff’s two treating physicians supported a disability finding but an examining neurophysiologist in a separate assessment found otherwise). [Footnote 2: “There is no obligation to weigh treating physicians’ opinions any differently than those of other doctors or specialists. The Supreme Court recently clarified that “courts have no warrant to require administrators automatically to accord special weight to the opinions of a claimant’s physician; nor may courts impose on plan administrators a discrete burden of explanation when they credit reliable evidence that conflicts with a treating physician’s evaluation.” Black & Decker Disability Plan v. Nord, 538 U.S. 822, 834 (2003).]

When we find an abuse of discretion, the discrepancies between the facts and the administrator’s findings are often stark. In Lain v. UNUM Life Ins. Co. of Am., a claimant had experienced serious chest pains and esophageal problems documented by multiple treating physicians. See 279 F.3d 337, 340–42 (5th Cir. 2002), overruled on other grounds by Metro. Life Ins. Co. v. Glenn, 554 U.S. 105, 115–19 (2008). Based on two internal reviews of the claimant’s medical files—one of which seemed to actually substantiate the individual’s complaints—and without an independent physical examination,[footnote omitted] the administrator denied benefits. See id. at 341–42. This court found an abuse of discretion, noting that there was a “complete absence in the record of any ‘concrete evidence’ supporting [the administrator’s] determination.” Id. at 347.

In this case, substantial evidence supported Reliance Standard’s decision to deny long-term disability benefits to Killen. While there is evidence in the record to support Killen’s claim for disability—which the district court recognized—there is also more than enough evidence supporting a denial to insulate the decision from reversal, particularly under our narrow review for abuse of discretion.

A downloadable copy of the Court’s decision is embedded below:

Download (PDF, 161KB)

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