Case Name: Cowern v. The Prudential Insurance Company of America
Court: United States District Court, District of Massachusetts
Type of Claim: Long Term Disability ERISA
Insurance Company: The Prudential Insurance Company of America (hereinafter Prudential)
Claimant’s Employer: Staples, Inc.
Disabilities: Gastrointestinal (“GI”) disorder – inflammatory bowel disorder, with symptoms including diarrhea, bloody stools, vomiting, exhaustion, fevers, abdominal pain and swelling, joint pain and swelling, nausea, and skin lesions.
Benefits Paid? Long Term Disability benefits were initially approved and then cut-off.
Issues: (1) Whether The Prudential abused its discretion in applying the Self-Reported Symptoms Limitation to the claimant’s LTD claim. (2) Whether Prudential’s review of her claim was improperly selective in various ways.
Background: This is how Prudential defined the term disability under the insurance policy:
“How Does Prudential Define Disability?
You are disabled when Prudential determines that:
* you are unable to perform the material and substantial duties of your regular occupation due to your sickness or injury; and
* you have a 20% or more loss in your indexed monthly earnings due to that sickness or injury.
After 24 months of payments, you are disabled when Prudential determines that due to the same sickness or injury, you are unable to perform the duties of any gainful occupation for which you are reasonably fitted by education, training or experience.”
The subject LTD Plan defines “self-reported symptoms” as follows:
“Self-reported symptoms means the manifestations of your condition, which you tell your doctor, that are not verifiable using tests, procedures and clinical examinations standardly accepted in the practice of medicine. Examples of self-reported symptoms include, but are not limited to headache, pain, fatigue, stiffness, soreness, ringing in ears, dizziness, numbness and loss of energy.”
The Prudential provides internal guidelines to the “LTD Teams” that evaluate claims for LTD benefits. This includes the following guidance on the SRS limitation:
“When evaluating a claim where the SRS limitation applies, you need to consider manifestations of the condition. Consider whether the manifestations are based in the claimant’s subjective reports or the product of objective findings. Consider whether the manifestation (i.e. feelings of pain, fatigue, dizziness, cognitive loss) can be linked to an objective finding (such as an MRI, x-ray, neuropsychological testing, et al.) If such a link cannot be made, application of the SRS limit may be appropriate. When evaluating such a situation, it is suggested that you consult with a clinical resource. An important distinction to be made when considering application of the SRS limit is that the manifestations of a condition should be the focus, rather than the diagnosis. Several diagnoses can be determined without the manifestations being verifiable.”
Holdings: (1) The District Court remanded this case to Prudential on the basis of other errors amounting to an abuse of discretion. However, the Court cautioned Prudential to interpret the SRS limitation and determines its applicability consistently with the language of the LTD Plan and Prudential’s internal guidelines. (2) The Court found that Prudential abused its discretion in relying upon a vocational assessment that was based only on Prudential’s hired external medical reviewer’s opinions rather than all of the medical evidence.
Summary: The District Court held there were “clear deficiencies in the integrity of Prudential’s decision-making process”:
Ms. Cowern further argues that “Ms. Grunden’s vocational review is substantively flawed as it found its basis on an incomplete record.” [Dkt. 55 at 19.] From the administrative record alone, it is not entirely clear to the Court which files Prudential provided to Ms. Grunden in connection with her vocational assessment. However, Prudential seems not to dispute that Ms. Grunden’s vocational opinion was based on only “external medical reviews”—i.e., those reviews done by physicians employed or retained by Prudential. [Dkt. 58 at 5.] Based on the ambiguity in the record and Prudential’s apparent acknowledgment that only “external medical reviews” were made available to Ms. Grunden, the Court proceeds on that understanding of which records Prudential provided to her.[fn 19: The Court notes, however, that it would have remanded this case even if Prudential had provided Ms. Cowern’s complete medical records to Ms. Grunden, based on the other errors addressed in this opinion.]
Ms. Grunden concluded from the partial record provided to her that “[t]he physical demands of claimant’s occupation appear within the capacity indicated” by the second multidisciplinary panel. [R. 2079.] Further, in its final appeal denial letter of August 29, 2013, Prudential relied in part on Ms. Grunden’s conclusion, stating that “[t]he vocational consultant concluded the restrictions and limitations outlined above are consistent with the physical requirements of Ms. Cowern’s occupation.” [R. 2267.]
The Court finds that Prudential abused its discretion by providing to Ms. Grunden an incomplete record, and by then relying on her opinion, which was based on the incomplete record. An administrator’s failure “to provide its independent vocational and medical experts with all of the relevant evidence” is evidence of arbitrary and capricious decision-making on the part of the administrator. Glenn, 554 U.S. at 118; see also Smith v. Cont’l Cas. Co., 450 F.3d 253, 261 (6th Cir. 2006) (“[T]here is clear evidence that there are discrepancies in the overall number of medical records that were provided to [the administrator] for review, and the number that were in fact reviewed by [the independent medical reviewer]. Without knowing why there are these discrepancies, it is impossible to say that [the administrator] did not artificially alter the record for [the independent medical reviewer’s] review. If [the administrator] did ‘hand-pick’ the records, then [the claimant’s] right to a ‘full and fair review’ of her disability denial was abridged.”). Absent any explanation for Prudential’s failure to provide portions of the record to Ms. Grunden, the Court cannot rule out the possibility that Prudential “hand-picked” the records sent to Ms. Grunden in an effort to lead her to conclude that Ms. Cowern was able to meet the physical demands of her occupation.[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: