In the instant case, Dee Ann Miller (“Miller”) was a senior collector who was employed by Springleaf Finance, Inc. (“Springleaf”). Miller’s job duties “include contacting customers with high risk accounts, negotiating repayment, providing documentation to monitor results and productivity of collection efforts, responding to inquiries, analyzing account status and obtaining information needed.” The physical demands of the position were “to occasionally reach and handle, frequently finger, and constantly talk and hear.”
In 1997, Miller received long term disability coverage under a group insurance policy through which The Hartford Life and Accident Insurance Co. (“Hartford”) issued a plan. The plan defined “Disability or Disabled” in the following terms:
“You are prevented from performing one or more of the Essential Duties of:
- Your Occupation during the Elimination Period;
- Your Occupation for the 24 months following the Elimination Period, and as a result, Your Current Monthly Earnings are less than 80% of Your indexed Pre-disability Earnings; and
- after that, Any Occupation.”
“Your Occupation” is further defined as “Your Occupation as it is recognized in the general workplace. Your Occupation does not mean the specific job You are performing for a specific employer at a specific location.” The plan also has limitations of twenty-four months as it relates to “Mental Illness that results from any cause” or “any condition that may result from Mental Illness.”
On March 5, 2014, Miller experienced a less than favorable performance evaluation. Thereafter, she did not return to work but alternatively applied for short-term disability benefits. Miller’s primary physician, Dr. Judy Brezausek, diagnosed her with fibromyalgia and depression. On March 13, 2014, Hartford granted Miller short term disability benefits which were to begin on March 17th. Over the next six months, Miller’s benefits were extended several times, eventually set to be run out on September 7, 2014.
On July 9, 2014, Hartford informed Miller that it would be considering her eligibility for long-term disability benefits, and it conditionally approved the same on August 14th. Following this approval, Miller applied for Social Security disability insurance benefits, which was a requirement under the plan. With her application, Miller submitted a “Function Report” which stated that she was bedridden as a result of her pain and fatigue and was unable to have conversations, follow television, or deal with money because of an inability to concentrate.
Later, M. Brill, M.D. did a Physical Residual Functional Capacity Assessment of Miller’s condition for the Disability Determination Bureau. He determined that Miller had the ability to sometimes lift or carry 20 pounds, more frequently lift or carry 10 pounds, stand or walk for about six of eight hours in a workday, and sit for about six of eight hours in a workday. Further, he stated that Miller did not have any manipulative restrictions. As a result of this examination, the bureau decided that Miller was not disabled, which led the Social Security Administration to subsequently deny Miller’s claim for benefits.
Later, Hartford had Dr. Marcus Goldman and Dr. Ibrahmin Alghafeer examine Miller’s file. Dr. Goldman pointed out that even though Miller was diagnosed with depression, she did not commit to dedicated mental health treatment for her condition. Further, Dr. Alghafeer noted that even though Miller had pain documented in her records, “[f]rom a rheumatology standpoint, restrictions are not supported.” Because of these two medical reports, Hartford ended Miller’s long-term disability benefits because she did not meet the definition of “Disabled” after May 6, 2015.
On October 28, 2015, Miller appealed the decision that Hartford made. As a result, Hartford had Dr. Brian Peck and Dr. Maureen Smith Ruffell examine Miller’s file. Overall, Dr. Ruffell stated that there was “inadequate support for the claim of mental/emotional symptoms so severe that they would be likely to preclude the claimant’s ability to function in the workplace despite them,” as “productive activity is generally considered a useful and necessary component of treatment for most mental/emotional conditions.” Additionally, Dr. Peck stated that Miller “is capable of performing light work as defined in the DOL-DOT on a full time basis” and the “reasons for limiting [Miller] to light work are her chronic pain and decreased [range of motion] due to lumbar spondylosis, [fibromyalgia], and [osteoarthritis] of the hands and feet.” After these file reviews, Hartford confirmed its denial of Miller’s benefits.
Miller filed the instant suit on January 20, 2016, but a discovery of additional information caused the court to remand the suit back to Hartford for consideration. After reviewing the additional information, Hartford again denied Miller’s claim wherein both parties filed for summary judgment on their issues. One of the main issues at hand is the reliability of Dr. Brezausek. While he stated that Miller had debilitating rheumatological and psychological limitations, he chose not to refer her to either a rheumatologist or a mental health professional until after her benefits were terminated. As such, the court believed that Dr. Brezausek seemed to perform “more as an advocate than a doctor rendering objective opinions.”
Next, Miller alleged that Hartford acted in an arbitrary and capricious manner when it disagreed with the Social Security Administration’s medical findings. However, the court decided that while Hartford did consider the SSA’s finding, it had the option to consider other evidence in the record which may have contradicted those findings. As such, the court did not find Hartford to be acting in an arbitrary and capricious matter related to this finding.
Miller also claimed that Hartford’s record reviewers focused on findings not relevant to fibromyalgia, that Hartford did not consider Miller’s complaints of pain, that Hartford terminated her benefits without evidence that her condition improved, and that Hartford relied on evidence that it did not cite in its denial letters. However – for each of these claims that Miller alleged – the court held that they had no merit. For a combination of all of the above reasons, the court ruled in favor of Hartford and against Miller.
[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: