Renee Killebrew v. The Prudential Insurance Company of America
The present case involves a suit that was appealed from a district court decision in Pennsylvania. Renee Killebrew (“Killebrew”) was employed by J. P. Morgan Chase Bank, N.A. (“Chase”). Killebrew began working for Chase on April 25, 2005, and ultimately advanced to the position of vice president and branch manager. Killebrew held a long-term disability (LTD) insurance policy that was administered by The Prudential Insurance Company of America (“Prudential”). She was later diagnosed with multiple sclerosis.
This case is on appeal from the lower District Court decision. Killebrew appealed the lower court’s decision, arguing that it improperly applied an abuse-of-discretion evaluation of the suit, instead of a de novo review. More specifically, Killebrew argued (1) that the court erred in its consideration of Prudential’s decision that she was not disabled and was unqualified for benefits, and (2) she argued that Prudential was arbitrary and capricious in its decision-making.
The appeals court ruled that the lower court properly reviewed the benefits denial under the abuse-of-discretion standard. According to the Viera case, the abuse-of-discretion standard should be used when a benefit plan allows for the administrator of the plan to determine whether a claimant is eligible for benefits. Here, the long term disability insurance plan that Killebrew held was under the Health & Income Protection Program for J.P. Morgan Chase Bank and Certain Affiliated Companies. That plan provided discretion to Prudential to determine Killebrew’s eligibility for benefits. Therefore, under the guidance of the Viera case, the instant court affirmed that the lower court properly applied the use of the abuse-of-discretion standard in lieu of a de novo review.
The next issue for review was whether Prudential was arbitrary and capricious in denying Killebrew’s LTD benefits. The court of appeal stated that there were three factors that were not in dispute:
- Prudential did not previously rely on opinions during its termination evaluation and later disregard those same opinions.
- The fact that Social Security disability benefits were granted to Killebrew indicate that Prudential may have slightly acted in an arbitrary and capricious manner.
- Prudential made an attempt to determine whether Killebrew had the ability to perform any employment that was gainful.
Additionally, the court of appeal held that there were several procedural issues that Killebrew brought up on appeal, but did not explain. Those procedural issues include whether Prudential failed to conduct a functional capacity or neuropsychological test, whether Prudential failed to make contact with Killebrew’s treating neurologist or the independent neurologist, and whether Prudential imposed a financial burden on Killebrew.
Instead of addressing those unexplained procedural issues, the court moved on to examine other issues that it could evaluate. Particularly, the court felt that there was a genuine issue of material fact related to whether there was enough evidence to show Killebrew’s restrictions as a result of her fatigue and pain. However, the court decided that it should remand the case back to the lower court to resolve issues relating to several procedural problems. Those three factors to be evaluated include: (1) whether Prudential acted in an arbitrary and capricious manner when it decided not to pursue an independent medical examination; (2) whether Prudential was acting in an arbitrary and capricious manner when it relied on its own experts’ opinions that were differing from those of Killebrew’s experts; and (3) whether Prudential was acting in an arbitrary and capricious manner when it ignored Killebrew’s fatigue and pain complaints.
The court of appeal did take some time to consider whether there was enough evidence to support Prudential’s finding of “no support” for Killebrew’s pain complaints. Prudential denied Killebrew’s benefits because it found “no evidence” to support restrictions based on subjective complaints. The abuse-of-discretion evaluation requires a court to defer to the administrator if its findings had “substantial evidence” supporting them. Here, the court of appeal did not find there was sufficient substantial evidence in the record to support Prudential’s decision.
Killebrew’s medical records evidenced that she had prescriptions for several chronic pain medications, including Cymbalta, Lyrica, and Neurontin. Even though those prescriptions were not narcotic pain medications and she may not have been prescribed pain management, the court held that the lack of narcotic pain medication alone does not support Prudential’s decision that there was “no evidence” of Killebrew’s restrictions as a result of her pain.
Similarly, the court did not feel that the lack of clinical evidence in the file supported Prudential’s determination of “no evidence” because the nature of Killebrew’s fatigue was undisputed and because Prudential failed to explain what sufficient evidence of the fatigue would be. Specifically, Prudential argued that there was no evidence of fatigue because Killebrew had muscle spasms which were not documented and were untreated. However, Prudential failed to explain that muscle spasms are objective evidence of fatigue. Instead, Prudential evaluated Killebrew’s spasms separately from her fatigue. As a result of the above, the court held that there is a genuine issue of material fact regarding whether there is evidence of the fatigue and subsequently, whether there were appropriate restrictions related to same.
The court of appeal determined that the lower court should determine whether there is enough evidence to support Killebrew’s complaints in order to determine the answers to the three procedural questions that it set forth above. Particularly, even though the lower court determined that Prudential did not have to conduct an independent medical examination and that there are objective ways to identify multiple sclerosis symptoms, Prudential still failed to show how Killebrew’s fatigue could be objectively tested and identified. This could result in a finding that Prudential acted in an arbitrary and capricious manner when it did not pursue an independent medical examination if evidence of restrictions based on fatigue can be found.
Additionally, the court of appeal held that the lower court will be able to similarly make a determination relating to whether Prudential was arbitrary and capricious when it relied on its experts over Killebrew’s treating physicians and when it ignored her pain and fatigue complaints.
In short, the court of appeal remanded the case back to the lower court to evaluate whether Prudential was arbitrary and capricious in its decision to deny Killebrew’s 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.] Killebrew_v_Prudential-USCOURTS-17-02137-0 (3d Cir)