Here, Melissa Maher (“Maher”) was a Manager of Research and Development at Bonne Bell, L.L.C. (“Bonne Bell”). Her job duties were considered to be light with sedentary demand. Further requirements were the ability to use ten pounds of force and other exertions of lesser amounts more frequently. Because of her employment with Bonne Bell, Maher was covered under a long-term disability plan administered by Prudential Insurance Company of America, et al (“Prudential”). The plan stated that:
You are disabled when Prudential determines that:
- you are unable to perform the material and substantial duties of your regular occupation due to sickness or injury; and
- you are under the regular care of a doctor; and
- you have a 20% or more loss in your 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; and
- you are under the regular care of a doctor.
In September of 2001, Maher was seen by Dr. John Gerace for fibromyalgia and Chronic Fatigue Syndrome. She also saw other doctors for other unrelated issues in the meantime. However, in December of 2004, Maher again saw Dr. Gerace, as well as a rheumatologist named Dr. Donna J. Sexton-Cicero, and a pain management specialist named Dr. Ellen Rosenquist. In 2006, Dr. Sexton-Cicero examined previous records that stated that Maher had fibromyalgia and antiphospholipid syndrome. However, Dr. Sexton-Cicero opined that she did not believe that Maher had antiphospholipid syndrome because she had not had any episodes.
Dr. Sexton-Cicero later stated that she believed Maher had Raynaud’s and then additionally suggested that she had Sjogren’s Syndrome. In January of 2009, Dr. Sexton-Cicero started referring to Maher as having Sjogren’s Syndrome. By June of 2010, Maher had a neurostimulator put in to assist with her chronic pain. On March 26, 2012, Maher stopped working for Bonne Bell because of her medical issues. She subsequently filed a claim for long-term disability benefits on July 23.
Prudential approved the claim for long term disability benefits with an effective date of June 24, 2012. During normal review processes, Dr. Sara B. Kramer reviewed Maher’s medical records. Most notably, she stated that there was nothing in the record to support why the Sjogren’s Syndrome diagnosis was made. Additionally, Dr. Kramer believed that Maher’s Activity of Daily Living Questionnaire (“ADLQ”) indicated that Maher could exert herself more than she indicated in the document. Later, in August 2013, Prudential terminated Maher’s long term disability benefits. The termination letter stated that Dr. Kramer’s review of the medical records, as well as an examination of Maher’s job duties, did not indicate that her medical issues sufficiently prevented her from performing her job.
In October of 2013, Maher appealed her claim. She provided additional letters from Dr. Sexton-Cicero and Dr. Rosenquist in support. Overall, the letters stated that the doctors recommended that Maher was unable to work with her issues and that her job would exacerbate her pain. Prudential then had an independent file review performed by Dr. Jeremiah Stubbs, an occupational medicine specialist. Dr. Stubbs also believed that Maher’s medical records did not support a finding a Sjogren’s Syndrome or indicate how that diagnosis was made in the first place. Additionally, Dr. Stubbs opined that even if there was the presence of Sjogren’s Syndrome, there was no medical explanation for how that diagnosis would have prevented Maher from working. Dr. Stubbs also stated that while Maher does have fibromyalgia, it was considered to be in a manageable condition. More specifically, Maher’s fibromyalgia would not affect her ability to perform any light or sedentary work. For these reasons, Prudential denied Maher’s appeal on February 24, 2014.
By August of 2014, Maher filed a second appeal. This time, Maher included another statement from Dr. Sexton-Cicero and a letter from Brian Williams, her supervisor. The statement from Dr. Sexton-Cicero again stated that Maher had Sjogren’s Syndrome. At this point, Prudential chose to have Dr. Julia Ash, a rheumatologist, review Maher’s medical records. She also concluded that Maher did not have Sjogren’s Syndrome because a biopsy was not done. Further, she also agreed that Maher had fibromyalgia, but that there were treatments available for this. Lastly, Dr. Ash opined that Maher’s ADLQ responses were unsupported by medical evidence. This resulted in a denial of the appeal in October of 2014, which subsequently resulted in this lawsuit.
Maher’s main arguments were that Prudential only sought out medical records for a twelve-month period and that the file reviews conducted during the appeals were not performed in a sufficient manner. Prudential argued that there was no requirement stating that it had to review medical records beyond a year. However, the court held that, if anything, a long-range examination of Maher’s records could have resulted in an arbitrary and capricious review because they would have shown that Maher had worked for almost an entire decade before she chose to file her claim. This could have in turn resulted in a simple dismissal of Maher’s claim without a more thorough review by Prudential.
Regarding the file reviews, Maher argued that she was neither examined by any of the file reviewers nor was she contacted by any of them. However, the court held that Prudential’s file reviews both done initially and over the two appeals processes were sufficient enough. Further, the court held that the methodologies of each file review by the doctors were not arbitrary and capricious in manner. For all of the above reasons, the court decided that Prudential’s denial of Maher’s benefits was not arbitrary and capricious. More specifically, Prudential relied on the opinions of three different physicians in order to make a decision regarding the denial of benefits. Therefore, the court denied Maher’s claim and ruled in favor of Prudential.
[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: