Calkin v. USLIC – Court Finds Reasonable Basis For Long-Term Disability Denial

Calkin’s treating physicians found him severely limited by a combination of shoulder, back, knee, and elbow conditions, restricting him to well below even sedentary work. USLIC’s own file-reviewing physician disagreed, concluding Calkin could still perform his regular occupation, and the court sided with USLIC — finding that a reasonable basis to deny the long-term disability (LTD) claim existed and that the medical record during the elimination period didn’t establish the disabling change in functional capacity ERISA requires.

Mr. Calkin suffered from impingement syndrome in his left shoulder, brachial plexopathy (a form of neuropathy), bilateral shoulder pain, lower back pain due to degenerative disc disease and stenosis in his lumbar spine, degenerative joint disease in his left knee, as well as pain in his right elbow. His conditions further required the use of opioids which carried a variety of side effects including fatigue, irregular sleep patterns, and difficulty focusing or staying on task.

Calkin needed to establish disability throughout his 182-day elimination period to qualify for benefits. USLIC’s policy defined “disabled” as meaning the company has determined that there has been a change in your functional capacity to work as a result of your sickness or injury, and that you are unable to perform all the material and substantial duties of your regular occupation due to your sickness or injury, and you have a 20% or more loss in indexed monthly earnings due to the same sickness or injury. Beyond 24 months of disability, the policy required either a 40% or more loss in indexed monthly earnings while working in any occupation, or an inability to perform the duties of any gainful occupation for which the claimant is reasonably fitted by education, training, or experience.

Mr. Calkin’s own treating physicians wrote Attending Physician Statements (APS) stating that he was severely disabled and found that Mr. Calkin had severe limitations putting him at below even sedentary exertional levels. Specifically, the second APS written by Mr. Calkin’s treating physician stated that he could only stand two hours at a time, could not stand or walk continuously even with standard employer breaks, and could only lift up to 5lbs. However, USLIC contracted a physician who reviewed Mr. Calkin’s medical records and made a determination without even seeing him in person. Based on just a review of the record, this contracted physician concluded that Mr. Calkin could still perform all the material and substantial duties of his regular occupation, even with some restrictions.

ERISA claims carry an “arbitrary and capricious” standard of review. This means that in order for a claimant to be successful there must be no “reasonable basis” for the insurance company to deny the claim. For Mr. Calkin, the report conducted by the physician hired by USLIC satisfied a reasonable basis to deny coverage.

The court ultimately found that Calkin’s medical records during the elimination period did not show that he was incapable of mere sedentary work. The court rejected all of Mr. Calkin’s treating physician opinions and Attending Physician Statements. While Calkin had many physical conditions that were ailing him, the medical records during the elimination time period found that he had good ROM (range of motion) in his bilateral shoulders and that both his knee as well as his elbow were not problematic during the elimination period.

The court also found that there was no change in Calkin’s functional capacity even though he did have physical ailments. The court then denied Calkin’s request for summary judgment and found that he was not disabled during the elimination period because he was not unable to perform all the material and substantial duties of his occupation due to his sickness or injury.

Here is a copy of the decision in PDF: Calkin v. USLIC

If USLIC or any other insurer has denied a claim for long-term disability benefits, it is imperative to consult an attorney before handling an appeal alone. Ortiz Law Firm has the experience needed to help claimants perfect their appeals and pursue the benefits they’re owed. Anyone whose long-term disability claim has been denied can contact the firm or call (888) 321-8131 for a free case evaluation.