Case Story: Our Client v. Nortel Networks Short Term and Long Term Disability Plan
ERISA case came to trial because the insurance company cherry-picked which medical information to give weight in determining the Plaintiff’s long term disability status. Specifically, the insurance company totally ignored the treating doctor. Also, the insurance company improperly ignored the Plaintiff’s complaints of pain and did not examine them. We sued the insurance company on behalf of our client, under ERISA because their long term disability benefits were denied. The court agreed that the insurance company was wrong, arbitrary, and capricious and reversed the termination of the Plaintiff’s long term disability benefits and remanded the case to Prudential for a proper decision.
After a year and a half of increasing back pain, our client had to stop working as a systems design engineer for Nortel Networks, Inc. They received short term disability benefits and some long term disability benefits before Prudential denied their long term disability benefits on May 18, 2005. Prudential gave credit to the April 2004 opinion of one of our client’s treating physicians, Dr. Gracer, and awarded long term disability benefits starting May 18, 2004. Yet, one year later, Prudential did not consider all of Dr. Gracer’s February 2005 “Work Status Form.”
Prudential focused only on the portions of the Plaintiff’s medical records from Dr. Gracer that were helpful to the Plan. Prudential emphasized Plaintiff could lift and carry up to 20 pounds occasionally; climb, bend, kneel, squat, crawl, and reach occasionally; balance frequently; and grasp, push and pull occasionally. Prudential even acknowledged that Dr. Gracer felt the Plaintiff was unable to engage in fine manipulation. Based on the medical information reviewed, Prudential decided these restrictions and limitations were reasonable. Yet, Prudential completely failed to mention the other limitations Dr. Gracer described, including ability to sit 1 hour, stand 1 hour, and walk 2 hours, all with rest, in an 8–hour workday, with no functional capacity to do any level of work, from sedentary to heavy. Instead of confronting this information in the Plaintiff’s favor, Prudential determined that Plaintiff could perform their prior job as a systems engineer, which Prudential classified as “light” work. Id. at 886-87 (italics added).
Similarly, there was another interesting error: the in-house doctor, Dr. Syrjamaki, totally ignored the treating doctor, Dr. Gracer. Specifically, he totally rejected the treating doctor’s opinion of restrictions, did not discuss it with him, and did not explain why he disagreed. Id. at 887 (referencing Calvert v. Firstar Finance, Inc., 409 F. 3d 286, 297 (6th Cir. 2005)(reversing and remanding for award of benefits where non-examining, consulting physician ignored conclusions reached by treating physicians and himself reached incredible determination)).
Prudential committed a third error by improperly ignoring our client’s complaints of pain and by failing to examine them to verify those complaints. Id. at 887-88 (referencing Platt v. Walgreen Income Protection Plan for Store Managers, 455 F.Supp.2d 734 (M.D. Tenn. 2006)(this Court reversed and remanded as arbitrary and capricious a plan administrator’s decision to terminate a claimant’s long term disability benefits without first obtaining an Independent Medical Examination (“IME”) as provided by the Plan). Such an examination likely could have provided information to Prudential about the extent of the Plaintiff’s pain. Id. at 888. Instead, Prudential simply relied on its paid medical file consultation with Dr. Syrjamaki to discredit the Plaintiff’s complaints of pain, ignore Dr. Gracer’s limits and restrictions, and uphold its decision to deny long term benefits. Id.
The court agreed with our assessment of the errors by the insurance company, and they agreed that the insurance company ignored relevant medical information in Plaintiff’s favor without explaining why it did so. Id. at 889. Therefore, the court reversed the decision to terminate our client’s long term disability benefits and remanded the case to Prudential for a proper decision. Id.