Case Name: Darlema Bey v. Reliance Standard Life Insurance Company
Court: U.S. District Court for the Eastern District of Pennsylvania
Date of Decision: February 17, 2017
Type of Claim: Long Term Disability
Insurance Company: Reliance Standard Life Insurance Company
Claimant’s Employer: Virtua Health
Disabilities: Ms. Bey was injured in a car accident in August 2011.
Definition of Disability in the Plan/Policy: By meeting the Policy’s initial definition of “total disability”—requiring that she be disabled from performing material duties of her regular occupation—she was awarded long-term disability benefits under the Policy. These benefits were paid for a period of two years, from February 4, 2012, to February 4, 2014.
To receive benefits beyond the initial two year period, however, Ms. Bey was required to satisfy a different definition of “total disability” under the Policy. The post-two year definition of “total disability” under the Policy is:
“[A]fter a Monthly Benefit has been paid for 24 months, an Insured cannot perform the material duties of any occupation. Any occupation is one that the Insured’s education, training or experience will reasonably allow. We consider the Insured Totally Disabled if due to an Injury or Sickness he or she is capable of only performing the material duties on a part-time basis or part of the material duties on a full-time basis.”
Other Key Definitions in the Plan/Policy: Further, the Policy included a maximum 24-month limitation for disorders caused, or contributed to, by mental or nervous disorders. See A.R. 24. In other words, in order for Ms. Bey to receive benefits beyond the first two years, she was required to show (1) that she was incapable of performing any occupation she was otherwise qualified for and (2) that a mental or nervous disorder did not contribute to her disability.
Benefits Paid? Yes. During the 2-year “own occ” period.
Basis For Denial / Termination of Benefits: To determine whether Ms. Bey could meet the heightened Policy definitions requirements to receive benefits beyond two years, Reliance obtained and reviewed the information in Ms. Bey’s claim file. By letter dated December 30, 2014, Reliance notified Ms. Bey that her claim was denied because Reliance had concluded, among other things, that she had transferrable skills that enabled her to perform other occupations. Moreover, Ms. Bey’s ongoing treatment for post-traumatic stress disorder triggered the 24-month maximum limitations on disorders to which mental or nervous disorders contributed. A.R. 198–203. The letter also explained that, while Ms. Bey was eligible for benefits through February 4, 2014, her benefits were subject to offset by Social Security disability benefits and the offset applied to payments after August 4, 2013.
Procedural history: Ms. Bey formally appealed her termination of benefits on June 15, 2015, and a flurry of communications followed.
Ms. Bey formally appealed her termination of benefits on June 15, 2015, and a flurry of communications followed. Reliance requested an independent medical examination (“IME”) in October 2015, and Ms. Bey refused to appear for the examination. Therefore, instead of relying on an IME, Dr. Kelly Allen, reviewed Ms. Bey’s medical records and issued a report. Dr. Allen concluded that she “[could] not adequately address the presence or absence of impairment as of 2/4/2014 as [she] [was] not . . . provided the ability to evaluate the claimant.” After she reviewed the records, she concluded that “there were no objective findings” as to the presence of impairment. Dr. Allen concluded that Ms. Bey would be able to work on a full-time basis, sitting for seven to eight hours and standing for one to two hours. She also noted that Ms. Bey suffered from post-traumatic stress disorder.
Reliance upheld its decision to deny benefits beyond February 2014 in a letter dated January 22, 2016.
Key Physician Opinions: Reliance requested an independent medical examination (“IME”)3 in October 2015, and Ms. Bey refused to appear for the examination. Therefore, instead of relying on an IME, Dr. Kelly Allen, reviewed Ms. Bey’s medical records and issued a report. Dr. Allen concluded that she “[could] not adequately address the presence or absence of impairment as of 2/4/2014 as [she] [was] not . . . provided the ability to evaluate the claimant.” After she reviewed the records, she concluded that “there were no objective findings” as to the presence of impairment. A.R. 2563-64. Dr. Allen concluded that Ms. Bey would be able to work on a full-time basis, sitting for seven to eight hours and standing for one to two hours. She also noted that Ms. Bey suffered from post-traumatic stress disorder.
Issues: (1) Reliance moved for summary judgment as to all of Ms. Bey’s claims. The summary judgment briefing focused on Ms. Bey’s ERISA claim and Reliance incorporated arguments made in its motion to dismiss regarding the state law claims and the ERISA penalty claim. Although she is not explicit, Ms. Bey appears to move for summary judgment as to only her ERISA claim.
(2) Ms. Bey primarily argues that Reliance’s determination was arbitrary and capricious because it failed to give proper credence to her treating physicians.
(3) Ultimately, an independent physician, Dr. Allen, reviewed Ms. Bey’s records for Reliance and concluded that she was unable to make an objective finding of total disability.
Holdings: (1) The Court finds that Ms. Bey’s state law claims are preempted by ERISA and that Reliance is entitled to summary judgment in its favor in all respects.
(2) She contends that administrators may not turn a blind eye to or refuse to credit evidence from treating physicians. See, e.g., Culley v. Liberty Life Assur. Co. of Boston, 339 F. App’x 240, 245 (3d Cir. 2009) (“[The administrator], operating under a potential conflict of interest, made decisions that disfavored the claimant at each ‘crossroads,’ and relied on expert opinions predicated on incomplete medical files.”). The United State Supreme Court has held, however, that ERISA plan administrators need not accord special weight to a claimant’s treating physician and are not required to explain “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).
(3) Given this thorough review by an independent physician, the Court cannot conclude that Reliance acted arbitrarily or capriciously in weighing Ms. Bey’s treating physicians’ statements.
Summary: For the foregoing reasons, the Court will deny Ms. Bey’s motion for summary judgment and grant Reliance’s.