In this case, David Diaz (“Diaz”) was the district manager at JM Family Enterprises, Inc. (“JM Family Enterprises”) between September 2010 and October 2015. JM Family Enterprises’ had an employee benefit plan which covered long-term disability benefits. This plan was insured by Liberty Life Assurance Company of Boston (“Liberty”). Under the plan, the term “disabled” means:
- that during the Elimination Period and the next 24 months of Disability the Covered person, as a result of Injury or Sickness, is unable to perform the Material and Substantial Duties of his Own occupation; and
- thereafter, the Covered Person is unable to perform, with reasonable continuity, the Material and Substantial Duties of Any Occupation.
“Material and Substantial Duties” are defined as “responsibilities that are normally required to perform the Covered Person’s Own Occupation or any other occupation, and cannot be reasonably eliminated or modified.” Additionally, the term “Elimination Period” is defined as “a period of consecutive days of Disability or Partial Disability for which no benefit is payable.”
In October of 2014, Diaz was injured in a work-related motor vehicle accident, which led to chronic neck and low back pain. He later submitted a claim for workers’ compensation and received recommendations for work restrictions. On November 3, 2014, Diaz was no longer restricted and returned to full-time work duty. By September 2015, Diaz had obtained a transfer from his location in Orlando to another location in Tampa and soon after ceased working. On April 1, 2016, Diaz submitted a claim to Liberty for long-term disability benefits as a result of chronic neck and low back pain, muscular spasms, left shoulder pain, degenerative disc disease, and adjustment disorder with mixed anxiety and depressed mood.
While Liberty began reviewing Diaz’s claim, it also requested a job description from JM Family Enterprises for his occupation. It was determined that the job was sedentary or light, depending on whether Diaz was traveling or at the office. On April 28, 2016, Diaz’s claim was denied for the reason that there was not enough evidence of a disability as defined by the plan. In October of 2016, Diaz sought an appeal for the denial of long-term benefits. However, Liberty upheld its decision, stating that
[W]e acknowledge that Mr. Diaz may have continued to experience some neck and back pain, and anxiety and depression, associated with his condition, beyond April 12, 2016. However, the information does not contain physical, cognitive, or psychiatric exam findings, diagnostic test results, functional capacities evaluation, hospitalization records, or other forms of medical documentation supporting Mr. Dolan’s [sic] symptoms remained of such severity, frequency, and duration that they resulted in restrictions or limitations rendering Mr. Dolan [sic] unable to perform the duties of his own Sales Manager occupation at either the sedentary of [sic] light physical demand level, after October 16, 2015.Diaz then filed suit on February 21, 2017, arguing that he should receive long-term disability benefits and stating that Liberty “failed to consider objective physical conditions and non-exertional limitations such as the effects of pain, impaired attention and concentration, and side effects of heavy narcotics.”
The main issue which the court must determine is whether Liberty’s denial of Diaz’s benefits was reasonably supported. Diaz claims that there are several reasons why Liberty was wrong in its denial. Firstly, Diaz believes that Liberty did not give enough weight to the results of the Functional Capacity Evaluation (“FCE”) that he underwent. However, Liberty’s Dr. Foland gave three reasons for discounting the results of the FCE. 1. Dr. Foland stated that the FCE results were inconsistent with the medical records that led up to the date that the FCE was performed. 2. Dr. Foland also opined that the person who conducted the FCE, Anthony Pribila, drew conclusions that were not supported by the results of the test. For example, Anthony Pribila indicated that Diaz was able to demonstrate full and consistent effort in all tasks, even though three of the grip and pinch strength tests were outside of the range that was valid, consistent, and reproducible. 3. Further, Dr. Foland also discounted the FCE because the reliability of using FCEs had not yet been fully established in research.
Secondly, Diaz argues that his “counseling records document restlessness, difficulty concentrating, irritability, e.g.” To support this argument, there is only a single document in the record. This document indicates that Diaz may have been moderately impaired from March 1, 2016, to April 7, 2016; however, the court held that that is not enough to show that Diaz was disabled through the whole Elimination Period.
Thirdly, Diaz claims that Liberty improperly relied on its own psychiatrists because they did not actually examine nor interview him themselves. He claimed that “courts routinely discount or entirely disregard the opinion of psychiatrists who have not examined the individual.” However, there are cases in the Eleventh Circuit where courts upheld denial decisions where consulting psychologists or psychiatrists were used. Here, Liberty’s consulting psychiatrists did not reach a conclusion that differed from Diaz’s own treating psychiatrists. More specifically, Dr. Forehand and Dr. Segal simply indicated that there was not enough documentation in the record to show that Diaz had any psychiatric limitations.
Fourthly and lastly, Diaz argues that his pain and side effects of his medication were not accounted for in Liberty’s decision-making process. The policy requires a showing that Diaz was unable to perform his material and substantial duties. However, the court found that the record provided no information that firmly established that Diaz’s pain or side effects from medication kept him from executing the material and substantial duties of his job during the entirety of the Elimination Period.
For all of the reasons above, the court held that Liberty’s decision to deny Diaz’s claim for long-term disability benefits was sufficiently supported. As such, the court believed that Liberty did not make an arbitrary and capricious decision related to Diaz’s benefits. Therefore, the court ruled in favor of Liberty, and ruled against Diaz, resulting in a denial of Diaz’s claim.
[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: