Case Story: Our Client v. Liberty Life Assurance Company of Boston
Our client had to stop working as a senior claims underwriter at AFLAC due to mixed connective tissue disorder, fibromyalgia, Reynaud’s phenomenon, and collagen vascular disorder. Dr. Martin, their primary care physician, diagnosed them with mixed connective tissue disorder. Id. Our client first took medical leave from AFLAC on October 8, 1999, and their claim for long term disability benefits was received by Liberty on February 3, 2000. Id. In the claim application, Dr. Martin stated that our client should be restricted to a daily maximum of four hours of clerical work and have limited exposure to stress and interpersonal relations. Id.
Since Liberty claims manager, Ms. Cancer, had no medical training, she relied on a nurse file reviewer to evaluate our client’s claim. Id. On March 15, 2000, the nurse was still waiting for additional office notes from another of our client’s physicians, Dr. Fox, and the nurse mailed Dr. Martin a questionnaire asking for the basis on which she had diagnosed our client with mixed connective tissue disorder; the nurse also asked whether Dr. Martin would recommend a psychiatric evaluation and requested Dr. Martin to respond by March 24, 2000. Id. at 255.
Also on March 15, 2000, Ms. Cancer denied the claim based on outdated office notes from Dr. Fox and later gave no explanation for denying the claim before the nurse’s review was complete. Id. at 255. Despite Ms. Cancer’s denial of the claim, the nurse reviewer continued her investigation and received additional information from Dr. Martin and Dr. Fox, learning that Dr. Fox had diagnosed his patient with mixed connective tissue disorder on February 16, 2000, and receiving the questionnaire from Dr. Martin detailing the basis of the mixed connective tissue disorder diagnosis and recommending a psychiatric consult. Id.
On May 16, 2000, our client wrote a letter to Liberty to appeal the denial of their claim, and this letter was reviewed by Ms. Malia, an appeal review consultant working as a contractor for Liberty. Id. Ms. Malia denied the appeal, relying on Dr. Martin’s recommendation that our client was capable of four hours of sedentary activity daily. Id. at 255, 256. Ms. Malia did not answer the question of how the mental limitations placed by Dr. Martin on our client would affect their ability to work; instead, she stated, “I would refer that question to a doctor.” Id. at 256. However, neither Ms. Malia nor any other Liberty agent referred our client’s case to a doctor for evaluation. Id. Additionally, Liberty did not employ any vocational expert or consultant to evaluate the demands of our client’s job as they related to the physical and mental restrictions assessed by Dr. Martin. Id.
When our client obtained disability benefits from the Social Security Administration, the administrative law judge found our client was “unable to sustain even this limited [part-time] amount of sedentary work.” Id. Liberty, informed of the favorable Social Security decision, declined to take into account that our client had received disability benefits from the SSA and denied them appeal again. Id.
The Court of Appeals for the Eleventh Circuit ultimately agreed with us that it was arbitrary and capricious to deny benefits. The Court of Appeals was very concerned that Liberty failed to analyze whether our client’s actual occupational duties were sufficiently sedentary, or whether the stress level and degree of interpersonal interactions were too demanding, in contravention of Dr. Martin’s recommendations. Id. at 259. The court also noted that Liberty failed to show that its decision to deny our client’s claim was not motivated by self-interest. Id. at 260. The court of appeals reversed the district court’s grant of summary judgment for Liberty and remanded the case to Liberty for a proper decision. Id.