Mr. Calkin was a 65-year-old manager of architectural design for AIG from June 10, 2013, through June 24, 2014. 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. Mr. Calkin sued United States Life Insurance Company in the City of New York (USLIC) pursuant to the ERISA act of 1974.
For Mr. Calkin to win his ERISA claim against USLIC he must have been disabled during his elimination period under the given insurance policy. Disabled means “the company has determined that there has been a change in your functional capacity to work as a result of your sickness or injury began while you are covered under the group policy 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.”
Further, “If you are disabled during the elimination period and the next 24 months, you will continue to receive payments beyond 24 months of disability, if you are also: working in any occupation and continue to have a 40% or more loss in your indexed monthly earnings due to your sickness or injury; or not working, and due to the same sickness or injury, are unable to perform the duties of any gainful occupation for which you are reasonably fitted by education, training, or experience.” Each elimination period is different, and Mr. Calkins was 182 days. In order to be eligible for benefits, the claimant must have a continuous disability during this elimination period.
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. Calkins 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 Calkins 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.
If USLIC or any other insurer has denied your claim for long term disability benefits, it is imperative to consult with our law firm prior to handling any appeal on your own. Our law firm has the requisite knowledge and experience to help you perfect your appeal and obtain benefits. If USLIC or any other insurer has denied your claim, please call us at (888) 321-8131 to evaluate your claim.
[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 copy of the decision in PDF: Calkins v. USLIC