• Menu
  • Skip to right header navigation
  • Skip to main content
  • Skip to secondary navigation
  • Skip to primary sidebar
  • Skip to footer

Before Header

Has your disability claim been wrongfully denied or terminated? Call us today for help!  (888) 321-8131

  • Facebook
  • Instagram
  • LinkedIn
  • Twitter
  • YouTube

National Disability Law Firm | Ortiz Law Firm

We appeal wrongful long term disability insurance and Social Security Disability denials.

  • ABOUT US
    • Our Team
    • Our Results
    • Areas We Serve
    • Core Values
  • PRACTICE AREAS
    • Administrative Appeals
    • Lawsuits
    • Lump Sum Settlement Offers
  • RESOURCES
    • Top 10 Mistakes That Will Destroy Your Long Term Disability Claim
    • Lump Sum Disability Settlement Calculator
    • Physical RFC Form
    • Mental RFC Form
    • Ultimate Appeal Checklist
    • Long Term Disability Case Study
  • BLOG
    • Long Term Disability Denials and Appeals
    • Medical Eligibility for Long Term Disability Claims
    • Eligibility for Long Term Disability Claims
    • Your Chances of Getting Approved for Disability Benefits
    • Additional Parts Of A Claim That Do Not Happen in Every Case
  • Search
  • CONTACT
  • ABOUT US
    • Our Team
      • Nick Ortiz
      • Jessica Ortiz
      • Dawn Keller
      • Tory Nelson
      • Sarah Palag
    • Core Values
    • Our Results
      • Why Choose Ortiz Law Firm
      • What Our Clients Say
      • Testimonials
  • PRACTICE AREAS
    • Long Term Disability Claims
      • Administrative Appeals
      • Lawsuits
      • Lump-Sum Settlement Offers
      • Qualifying Conditions
      • Disability Insurance Companies
      • Qualifying Occupations
      • Case Summary Archives
      • FAQs
    • Social Security Disability Claims
      • Initial Application
      • Request for Reconsideration
      • Hearing Before an Administrative Law Judge
      • Qualifying Conditions
      • FAQs
    • Personal Injury Claims
      • Car Accident Claims in Pensacola, Florida
      • Bicycle Accident Claims in Pensacola, Florida
      • Motorcycle Accident Claims in Pensacola, Florida
      • Truck Accident Claims in Pensacola, Florida
      • Slip & Fall
      • Insurance Companies
      • FAQs
  • AREAS WE SERVE
  • RESOURCES
    • Top 10 Mistakes That Will Destroy Your LTD Claim
    • Top 10 Mistakes That Will Destroy Your SSD Claim
    • Lump Sum Disability Settlement Calculator
    • Physical Residual Functional Capacity Form
    • Mental Residual Functional Capacity Form
    • Ultimate LTD Appeal Checklist
    • LTD Case Study: Fibromyalgia
    • Top 10 Mistakes That Will Destroy Your FL Car Accident Claim
  • BLOG
    • Long Term Disability
      • Eligibility for Long Term Disability Claims
      • Medical Eligibility for Long Term Disability Claims
      • Your Chances of Getting Approved for Disability Benefits
      • Long Term Disability Denials and Appeals
      • Additional Parts Of A Claim That Do Not Happen in Every Case
    • Social Security Disability
    • Personal Injury
  • REFER A CASE
  • Search
  • CONTACT

Mobile Menu

Schedule A Free Consultation Now!

Find out how our law firm can help you win your case or you don’t pay a cent.

(888) 321-8131

  • Facebook
  • LinkedIn
  • Twitter
  • YouTube

Substantial Evidence Supports Decision to Terminate Claim

April 7, 2020

Case Name: Gilewski v. Provident Life and Accident Insurance Company

Court: U.S. Court of Appeals for the Sixth Circuit, on appeal from the U.S. District Court for the Western District of Michigan

Date of Decision: March 22, 2017

Type of Claim: Long Term Disability pursuant to ERISA

Insurance Company: Provident Life and Accident Insurance Company

Claimant’s Occupation / Job Position: Gilewski, born in 1968, was the owner and president of Radiance Mold and Engineering, Inc., an auto supplier in Michigan, for 20 years.

Disabilities: Anxiety and Depression

Definition of Disability: The policy at issue required Provident to pay monthly benefits to a participant who satisfies various conditions, including being disabled within the meaning of the term as defined by the policy. The policy states:

Disability, or disabled, means that, due solely to Injuries or Sickness:
1. you have a Loss of Time or Duties in your occupation; and
2. you have a Loss of Earnings of at least 20%.
. . .
Loss of Time or Duties means that:
1. you are not able to perform one or more of the substantial and material duties of your occupation; or
2. you are not able to perform the substantial and material duties of your occupation for as much time as you regularly performed them before you became disabled.
. . .
Your occupation means the occupation . . . in which you are regularly engaged at the time you become disabled.

Benefits Paid? Yes.

Basis For Denial / Termination of Benefits: Provident paid LTD benefits under the second of two policies, but, after four years, it terminated the benefits after it determined that Gilewski was “able to perform the duties of his occupation” and was no longer disabled under the terms of the policy.

Procedural History: After exhausting Provident’s administrative appeals, Gilewski brought this action against Provident. The district court granted judgment on the administrative record to Provident. The Sixth Circuit affirmed.

Other Important Factors: On June 19, 2013, a Dr. Dudley performed an “independent medical examination”. Dr. Dudley diagnosed Gilewski with “Major Depressive Disorder, Unipolar, stabilized,” and assigned him a Global Assessment of functioning score of 80. Dr. Dudley concluded that Gilewski did not require a psychiatric disability status and that he was able to return to work without restrictions.

Key Physician Opinions: In November 2010, Gilewski underwent a forensic psychiatric examination as part of his bankruptcy proceeding. He was examined by Dr. Gerald Shiener, a board-certified psychiatrist. Dr. Shiener diagnosed Gilewski with “Major depression, recurrent and chronic,” and concluded that Gilewski’s “current condition is incompatible with any sort of competitive employment.”

Issue: The sole issue on appeal is whether the district court erred in holding that Provident’s decision to terminate Gilewski’s long-term disability benefits was supported by substantial evidence in the administrative record. Gilewski’s primary complaint is that the Provident did not give enough weight to the opinion of his treating physician, Dr. Shiener, and relied instead on the opinions of non-treating psychiatrists, only one of whom had actually examined Gilewski. Gilewski also contends on appeal that the district court erred in not requiring Provident to consider the evidence submitted by Gilewski regarding a vocational expert who opined about the demands of Gilewski’s occupation, and he also maintains that the administrative process was marred by a conflict of interest because Provident is both the decisionmaker and the payor of benefits.

Holdings: However, the court concluded that the evidence does not support the plaintiff’s claim.

“In addition to a dearth of information from Dr. Shiener, the attending physician statements and reports he did provide were incompatible with Gilewski’s self-reported activity level and abilities in 2012 and 2013, as well as with the other medical opinions, including the opinion of Dr. Dudley, who performed an independent medical examination on Gilewski in June 2013, and the file reviews of Dr. Szylk, Provident’s in-house psychiatrist, and Dr. Brown, the independent reviewer for the administrative appeal. The nontreating physicians all agreed with Dr. Shiener’s diagnosis of major depressive disorder, but the non-treating physicians believed the condition to be “stabilized” and well-treated with Gilewski’s current medications. Dr. Dudley noted that if after four years of treatment Gilewski’s condition and prognosis were as poor as Dr. Shiener believed, Gilewski should be receiving more intensive treatment through changed medications, intensive psychotherapy, or even in-patient treatment at a psychiatric facility. Even after Dr. Dudley sent his report to Dr. Shiener, Dr. Shiener gave no indication that he though a change in treatment was needed at that time.”

Noteworthy Court Comments: “Generally speaking, an administrator may not summarily reject the opinions of a treating physician, but must instead give reasons for adopting an alternative opinion.” Elliott v. Metro. Life Ins. Co., 473 F.3d 613, 620 (6th Cir. 2006). Administrators, however, are not obligated to accord special deference to the opinions of treating physicians.

Summary: In conclusion, reviewing the administrative record and giving no deference to Provident’s decision to terminate benefits, we find substantial evidence supports Provident’s decision to terminate Gilewski’s long-term disability benefits.

Disclaimer: This was not a case handled by disability attorney Nick A. Ortiz. The court case is summarized here to give readers a better understanding of how Federal Courts decide long term disability ERISA claims.
Here is a copy of the decision in PDF:
Gilewski v. Provident

Insurance Company: Provident LifeOccupation: Owner

Primary Sidebar

View All Resources


Terry V.

I can say with all this unnecessary stuff that going on with this world including the COVID-19 pandemic, Ortiz, Tory, and his professional staff worked through the process of winning my case. I thank God for them every day for making my life continue without any worries. They answer every question you have even if it simple. Very southern hospitality. Thank you again, guys, you are great and I will recommend anyone going through anything use the source Ortiz Law Firm and may God continue to lay hands and bless you.

View All Testimonials

Complete this CONFIDENTIAL form or call (888) 321-8131 for a FREE case evaluation

  • This field is for validation purposes and should be left unchanged.

Navigation

  • Free Resources
  • Qualifying Conditions for LTD
  • LTD Insurance Companies
  • Qualifying Occupations for LTD
  • Case Summary Archives
  • LTD FAQ
  • Qualifying Conditions for SSD
  • SSD FAQ
  • PI FAQ
  • PI Insurance Companies
  • Disclaimer

Footer

Our Team

  • Nick Ortiz
  • Jessica Ortiz
  • Dawn Keller
  • Sarah Palag
  • Tory Nelson

Our Law Office

ORTIZ LAW FIRM
(888) 321-8131

823 E. Jackson St.
Pensacola, FL 32501
Monday - Thursday: 9:00 AM - 5:00 PM Friday: 9:00 AM - 2:00 PM

Saturday - Sunday: Closed

Practice Areas

  • Long Term Disability Claims
  • Social Security Disability Claims
  • Personal Injury Claims
  • Facebook
  • LinkedIn
  • Twitter
  • YouTube
  • Free Long Term Disability Resources
  • Long Term Disability Frequently Asked Questions
  • Medical Conditions That May Qualify for Long Term Disability
  • LTD Insurance Carriers
  • Occupations That May Qualify for LTD
  • LTD Blog
  • LTD Federal Court Case Summaries
  • Contact
  • Disclaimer

Site Footer

©2020 Ortiz Law Firm, All Rights Reserved. Reproduced with Permission | Privacy Policy