In this case, Amanda Foster (“Foster”) worked as an attorney for Sullivan, Stolier & Knight (“Sullivan”) in New Orleans. Her duties involved being able to “review and draft leases and agreements; research and advise clients regarding government laws and regulations; represent clients in administrative appeals; [and] draft compliance plans.” When Foster had been working for the firm for almost eight years, she switched her work hours to part-time because she had been experiencing headaches. On July 1, 2013, she completely stopped working and fully took disability leave.
Foster’s employer had a group insurance benefits policy that provided long-term disability benefits. Principal Life Insurance Company (“Principal”) was the insurer of the policy. The policy defines the term “disabled” as when a person “cannot perform one or more of the substantial and material duties of his or her Own Occupation.” “Substantial and material duties” are “essential tasks generally required by employers from those engaged in a particular occupation that cannot be modified or omitted.” “Own Occupation” is in this case defined as “[t]he specialty in the practice of law the Member is routinely performing for the Policyholder when his or her Disability begins.”
In July of 2013, Foster filed for long-term disability benefits claiming that she was “unable to practice law due to the pain of headaches as of March 8, 2013.” In support of her claim, she provided a statement from her neurologist, Dr. Mohnot, which showed that Foster experienced “intractable migraines” and that she had been advised to stop working on March 8th. Foster also submitted records from her psychotherapist, Dr. Phyllis Shnaider, in support of for claim. After a mandatory 180-day elimination period expired, Principal chose to provisionally approve Foster’s claim for the dates of September 4, 2013, to December 9, 2013.
Principal began surveillance on Foster on November 4, 2013. The surveillance indicated that Foster had been able to go shopping and pick up her children. Principal then requested an update of Foster’s medical records. A Dr. Ethel Condon stated that Foster’s “chronic headaches and intractable migraines” would disallow her from seeking “consistent full-time employment” for “sedentary work.” Similarly, a Dr. Pranathi Kondapaneni stated that Foster’s headaches caused her “functional impairment” which led to part-time work to avoid “work-place stress and light exposure.”
In the meantime, Principal had two physicians review Foster’s file. A Dr. Sydney Kroll Register, psychologist, stated that “[t]here is no indication of functionally impairing psychological symptoms,” and he further indicated “generally mild psychological symptoms consistently across time.” Dr. Register also stated that “[n]o limitations are supported” which would cause Foster the “total inability to perform any type of occupation.” Additionally, a Dr. David Hoenig, neurologist, opined that Foster’s files indicated “no objective/clinical evidence which demonstrates that Mrs. Foster is functionally impaired.”
Dr. Hoenig also believed that “Ms. Foster has capabilities to perform work activities on a full-time basis, in a sedentary capacity.” More specifically, he opined that “Based on the documentation provided, . . . the recommendation that [Foster] not work is not reasonable and is not medically supported,” because “[t]here is no clinical evidence that demonstrates that Ms. Foster is functionally impaired.”
On December 18, 2014, Principal stopped providing Foster’s long-term disability benefits. Its reasoning was that Foster’s “subjective complaints did not correlate with objective findings” and her “reported functional and daily activity level was not consistent with the severity of the complaints [she] reported.” In addition, Principal cited that Foster was “seen on video surveillance to be functional and apparently without activity limitation.” Foster then chose to appeal on April 28, 2015, providing more medical records and letters from Dr. Mohnot, an independent medical examination (IME) from Dr. Shelly Savant, and a letter from a founder of the law firm regarding her incapacity to work.
Principal countered this appeal by having another two doctors review the records. A Dr. Daniel Harrop, psychiatrist, opined that “[t]he medical documentation does not support that there are restrictions and limitations which would render [Foster] unable to perform the occupation she regularly performs[.]” Further, a Dr. Norman Miller, psychiatrist and neurologist, stated that Foster had “opioid dependence,” “opioid inducted mood disorder,” and “opioid induced hypalgesia and somatoform disorder.” Further, he indicated that “[…] the nature of her headaches all will improve once she no long is prescribed and uses hydrocodone.” Principal then denied Foster’s appeal, to which she responded with a second appeal.
Principal had an independent neuropsychological examination performed which led the evaluating psychologist to opine that “[t]here is no real evidence of psychologically or neuropsychologically based impairment in [Foster’s] ability to carry out tasks.” Partially based on this statement, Principal again denied Foster’s appeal. Foster then filed suit, but the court rendered judgment in favor of Principal. Foster then appealed that decision in the present action.
Firstly, Foster claimed that Principal committed an abuse of discretion when it terminated her benefits because it did not analyze her condition in concert with her lawyerly job duties. The present court held that the psychologist who performed the independent neuropsychological examination, at minimum, considered Foster’s conditions in relation to her job description, among other sufficient amounts of evidence that Principal provided. In fact, the instant court believed that Principal provided enough evidence to indicate that it had not abused its discretion in its decision-making processes.
Secondly, Foster argued that Principal should not have denied her claim for lack of “objective or clinical evidence” when she alleges that migraine verification should be confirmed by subjective evidence. The court concluded, however, that Principal did not so much rely on how Foster experienced her migraines, but instead relied on the expert opinions relating to whether such migraines prevented her from working. Therefore, the court decided that Principal did not commit an abuse of discretion when it relied on its treating physician’s reports explaining Foster’s alleged impairments.
Overall, because the court did not find Principal to have committed an abuse of discretion in either of Foster’s two arguments, it ruled in favor of Principal and against Foster.[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: