Court: United States District Court for the Southern District of Florida
Insurance Carrier: The Guardian Life Insurance Company of America
Claimant’s Employer: Contec, LLC
Claimant’s Occupation: Shipping Supervisor
Hari Sami was employed as a shipping supervisor for Contec, LLC in Florida when he suffered a transient ischemic attack (TIA, or more commonly referred to as a “mini-stroke,” caused by a temporary disruption of blood flow to the brain) in 2016, resulting in disabling symptoms including dizziness, migraines, chronic pain, vertigo, and vision problems.
He began receiving short-term disability and then long-term disability (LTD) benefits under a policy provided by his employer and administered by The Guardian Life Insurance Company of America.
Initially, Guardian acknowledged that Sami’s symptoms prevented him from performing his own job. But after two years, the policy’s definition of disability changed. Sami now had to prove that he was unable to perform any gainful employment for which he was reasonably qualified. Guardian continued to pay benefits until July 2020.
Benefits Terminated Without a Chance to Respond
Although his treating physician continued to state that he was unable to work due to persistent vertigo and related symptoms, Guardian terminated Sami’s benefits in July 2020. Guardian claimed that he no longer met the LTD definition of disability.
Sami appealed the decision. During the appeal, Guardian commissioned a peer review and a vocational report, which concluded that Sami could perform other types of work. In December 2020, Guardian notified Sami of its final decision to uphold the termination of his LTD benefits on appeal.
Guardian’s final decision relied heavily on the findings of the two peer review physicians—a neurologist and an internal medicine and occupational medicine specialist—who concluded that there was no functional impairment. It also cited the vocational report, which had identified several positions that Sami was capable of performing or could become qualified to perform.
However, Guardian failed to share these reports with Sami until the same day it issued its final denial—in violation of ERISA regulations that require advance disclosure of adverse evidence in advance to give the claimant an opportunity to respond.
Court Finds Procedural Violation by Guardian
The court ruled that Guardian violated ERISA’s procedural protections by denying Sami a full and fair review. According to DOL regulations updated in 2018, insurers must provide claimants with any new evidence or rationale for a denial “sufficiently in advance” of a final decision. Guardian failed to do so.
The court rejected Guardian’s arguments that it met its obligations by providing Sami with the reports as soon as they were completed, or that Sami waived his rights by refusing to extend the appeal period. It emphasized that Guardian was responsible for complying with the timing and disclosure requirements regardless of Sami’s actions.
Guardian even went so far as to argue that “even if [it] committed a technical procedural violation[,] . . . that violation was de minimis and did not impact Guardian’s full and fair review of Mr. Sami’s claim.”
The court found this claim to be absurd. This procedural violation deprived Sami of a full and fair review under ERISA.
Case Sent Back for a Full and Fair Review
Because the procedural error deprived Sami of a meaningful opportunity to respond to the key medical reports used to deny his claim, the court did not rule on whether Guardian’s decision was substantively correct. Instead, it remanded the case to Guardian for a new decision that would give Sami a fair opportunity to respond to all the evidence.
The court declined to award attorneys’ fees at this stage, noting that it had not ruled on the merits of the disability determination.
You Deserve a Fair Disability Review—Let Us Fight for You
If your disability benefits have been denied or terminated because the insurance company didn’t give you a fair chance to respond to new medical evidence, the Ortiz Law Firm can help. We help clients nationwide hold insurers accountable to ERISA regulations and protect the rights of disabled workers. Contact us online or call (888) 321-8131 today for a free case evaluation.
Disclaimer: Please note that this claim was not handled by the Ortiz Law Firm. It is summarized here for educational purposes.
Here is a PDF copy of the decision: Sami v. Guardian
