Anthony Bowman (“Bowman”) was employed as a Maintenance Mechanic which required the ability to do heavy lifting between fifty and sixty pounds. Injuries throughout his life caused him to have a number of surgeries and resulted in chronic neck and back pain. Bowman also had issues with a sleep disorder and pain medication, which led to problems with concentrating and performing sedentary tasks. As a result of his injuries, Bowman applied for disability benefits with Reliance Standard Life Insurance Co. (“Reliance”).
Reliance approved the disability application because Bowman could not perform his duties as a Maintenance Mechanic. Subsequently, he was also approved for disability benefits by the Social Security Administration. After a two-year period of paying benefits, Reliance’s policy required a re-evaluation of the long-term disability benefits. The definition of total disability after the two years required that the claimant be unable to perform any job duties, not simply his previous job’s duties.
At this time, Reliance provided Bowman with a questionnaire and contacted his three physicians: Dr. Cordover, Dr. Connolly, and Dr. DeBerry. Dr. Cordover suggested that Bowman could “perform[] full-time work” with few limitations, but had concerns about “repetitive bending, squatting, stopping, etc.” In addition, a specific part of the questionnaire asked whether Bowman’s medications caused: “(1) no significant effect, (2) some limitations, (3) severe and limiting side effects, or (4) total restriction and inability to function productively.” Dr. Cordover cited that the medications that Bowman was taking caused “severe and limiting side effects.”
Dr. DeBarry stated that “[i]t has been determined that [Bowman] is disabled . . . and in my opinion has not improved over the past 2-3 years.” He did, however, “defer all functional capacity evaluations and further prognosis to [Bowman’s] back specialist Dr. Cordover.” Dr. Connolly, Bowman’s doctor who treated him for idiopathic hypersomnia and obstructive sleep apnea, was also contacted but provided no comments on Bowman’s disability level.
Reliance then decided that while Bowman did have a disability, he was not totally disabled under their definition because he was not unable to work in any capacity. Therefore, Reliance denied Bowman’s claim. Bowman then appealed, and in the meantime, Reliance received information from Dr. Cordover citing Bowman’s “progressing” neck symptoms, but also citing “no change in [Bowman’s] restrictions or forms that [Dr. Cordover] ha[d] filled out previously.” Reliance then sought to obtain evaluations from a Dr. Denver and Dr. Goldstein, both independent medical examiners.
Dr. Denver reviewed Bowman’s medical files and eventually opined that Bowman was able to perform full-time work with light physical demand, as long as he could change positions every forty minutes. He cited that Bowman’s “current medications . . . do not contribute to any significant limiting physical or cognitive deficits” and that he “reports hydrocodone worsens insomnia and dulls his senses[,] but the documentation fails to substantiate significant impairment in cognition or physical function resulting from hydrocodone use.”
Dr. Goldstein also evaluated Bowman and believed that he would be able to work if he only had issues related to narcolepsy, sleep apnea, and hypersomnia. However, he also stated that Bowman could not “return to his work as [Bowman] described” which meant the Maintenance Mechanic work. Overall, because of these two independent medical examinations, Reliance chose to deny Bowman’s appeal. Bowman then filed the instant suit, arguing that Reliance’s decision was arbitrary and capricious. However, more particularly, the question is whether Bowman is able to do the work of any job or not.
An arbitrary and capricious “standard of review does not mean that the plan administrator will prevail on the merits. It means only that the plan administrator’s interpretation of the plan ‘will not be disturbed if reasonable.’” If “no reasonable basis exists for the decision,” then Reliance’s decision will be considered to have been arbitrary and capricious. Further, “[w]hile an administrator may not arbitrarily ignore relevant medical evidence, it is not arbitrary and capricious to deny a disability claim ‘on the basis of conflicting, reliable evidence.’”
Bowman first argued that his treating physicians cited a “substantial and progressive decline in health,” while Reliance “arbitrarily and capriciously relied on a May 2009 claim form to support its contention that it had grounds to deny [his] claim in 2011 . . .” However, the Court held that even though Reliance had reviewed the form, it supplemented that information with the independent medical examiners’ opinions. Therefore, its decision had focused on “the facts as known to the administrator at the time the decision was made,” and the Court believed that that action was reasonable.
Secondly, Bowman argued that he had provided “significant probative evidence” of his disability by citing information from his doctors. However, the Court explained that providing such evidence is not the baseline of what Bowman needed to do to overcome Reliance’s decision. The standard of review that Bowman needed to prove was that he was unable to perform the work of any job. Here, he did not do that.
Third, Bowman claimed that Reliance had not properly evaluated the effects his medications had. He specifically stated that they “affect his ability to perform work functions, drive to and from work, [and] to stay awake during the workday.” This argument was based on a case called Adams v. Prudential Insurance Company of America, where treating physicians completely ignored the claimants’ medications. However, the Court cited that Dr. Denver opined that Bowman’s medications “do not contribute to any significant limiting physical or cognitive deficits.” Because Reliance had indeed considered Bowman’s medications, it did not act in an arbitrary and capricious manner.
Overall, the Court’s decision was to determine whether Reliance acted in a reasonable manner when denying Bowman’s claim. It opined that “it is not arbitrary and capricious to deny a disability claim ‘on the basis of conflicting, reliable evidence.’” Here, Reliance based its decisions on evidence that was reliable, therefore, its decision to deny Bowman’s claim was not unreasonable. Thus, the Court ruled in favor of Reliance and against Bowman.
[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: