Successful Legal Summaries

At Eric Buchanan & Associates, our team has helped many people fight denials of disability insurance, ERISA insurance, and similar insurance claims. Here are examples of our successful cases.

A special rule from ERISA case law in the Second Circuit applied to this case because MetLife failed to issue a proper decision letter regarding an appeal. The court questioned the “correctness” of MetLife’s original assessment and ruled in our client’s favor.

Landry v. Metropolitan Life Insurance Company
No. 19 CIV. 3385 (KPF), 2021 WL 848455 (S.D.N.Y. Mar. 5, 2021)

Our client became disabled after working as an oil field equipment mechanic. MetLife tried to offer him a substantially lower amount in short-term disability benefits than he was owed and he hired us to help rectify. MetLife refused to provide information that governed our client’s short-term disability insurance policy, so we brought suit against them on our client’s behalf.

Initially, MetLife tried to argue that our client waited too long to file a lawsuit, stating that the policy required any legal action to be taken within three years of receipt of benefits. Our client had never received a copy of this plan, however, and was not aware of this policy. We argued to the court that previous rulings had been made in favor of plaintiffs who were not afforded reasonable review of their governing policy, and that New York’s six-year statute of limitations should apply instead.

MetLife also argued that because our client had never submitted a letter including the exact word “appeal,” he had never submitted an appeal in fact. The court disagreed, and found that a letter containing request for “review” was sufficient language to make MetLife aware that their benefit decision was in contest.

MetLife’s arguments against multiple ERISA rules were dismissed, with the court saying that because MetLife failed to adhere to ERISA regulations, the court would apply the de novo standard of review. After conducting the review, which included key financial information that supported our client’s claim for a higher benefit, the court determined that MetLife had made their decision based upon an “incomplete record,” and remanded the claim back to MetLife, instructing them to provide a full review of our client’s appeal.

To learn more about Landry v. Metropolitan Life Insurance Company, see more.

The court ordered UnumProvident to comply with our discovery request regarding Unum’s potential biases against granting our client’s claim for benefits.

Williamson v. UnumProvident Corp.
Nos. 1:04-CV-162,1:04-CV-163, 2005 WL 6731769 (E.D.Tenn. Oct. 21, 2005)

Our client became disabled but was denied benefits, so we sued our client’s plan administrator UnumProvident. In this ruling, the court granted our discovery request, meaning we could obtain more information about how UnumProvident might have treated our client unfairly, and had practices and procedures in place that favored denying claims.

Discovery such as this is somewhat rare because courts generally rely on the administrative record, which contains the information that the insurer relied on in making its eligibility determination. However, in certain cases, discovery is granted where necessary to prove clear bias in claims handling. This instance involved such bias.

We asked for additional discovery of UnumProvident’s employee files with respect to those employees or consultants that participated in the evaluation of our client, along with any information as to any bonuses received by those employees or consultants. The district court granted our request because we established a reasonable basis for alleging that UnumProvident may have engaged in unfair claims handling procedures. The court ruling allowed us to further explore whether UnumProvident engaged in unfair claims handling to the detriment of our client.

To learn more about Williamson v. UnumProvident Corp., see more.

Boersma v. Unum Life Ins. Co.
546 F.Supp.3d 703 (M.D. Tenn. 2021)

Our client was a successful executive but had to stop working due to a physically disabling condition. Our client had disability coverage through her employer, and Unum was the claims administrator. After our client stopped working, Unum paid her short-term disability benefits, and later long-term disability benefits for some time, before it decided that her condition was not sufficiently disabling to qualify for benefits.

Our client appealed that decision with our help; we submitted additional medical records, sworn statements, and results from a functional capacity evaluation that all supported her disability. Unum employed its own reviewers, and ultimately, affirmed its denial of our client’s claims. It did not believe that our client had a condition that prevented her from continuing to work in her position.

We sued, and the court agreed with us that Unum’s arguments against our client’s disability were insufficient. Our client was entitled to disability benefits, and the court ordered Unum to pay her.

To learn more about Boersma v. Unum Life Ins. Co., see more.

Barnes v. Unum Life Insurance Company of America 
No. 1:19-CV-138, 2020 WL 10221073, at *1 (E.D. Tenn. Nov. 24, 2020)

Our client worked as the CEO of a medical clinic, overseeing over 100 employees and “meet[ing] the day to day demands of 12 physicians and 4 nurse practitioners.” Barnes v. Unum Life Ins. Co. of Am., No. 1:19-CV-138, 2020 WL 10221073, at 1 (E.D. Tenn. Nov. 24, 2020).

Our client also served as a consultant for two other companies; all his work was sedentary. Id.

Unum Life Insurance provided long-term disability coverage to our client through his employer. Unum’s policy provided benefits for the first 24 months of disability if he was “unable to perform the material and substantial duties of [his] regular occupation and [is] not working in [his] regular occupation or any other occupation” or “unable to perform one or more of the material and substantial duties of [his] regular occupation, and [he has] a 20% or more loss in [his] indexed monthly earnings while working in [his] regular occupation or any other occupation.” Id.

If our client remained disabled after 24 months, he could get continued benefits if he was “unable to perform the duties of any gainful occupation for which [he is] reasonably fitted by education, training, or experience.” Id. The policy also defined a “gainful occupation” as one “that is or can be expected to provide [him] with an income within 12 months of [his] return to work, that exceeds” either “80% of [his] indexed monthly earnings, if [he is] working” or “60% of [his] indexed monthly earnings, if [he is] not working.” Id. The policy also limited benefits to 24 months if disability is caused by a mental health condition. Id.

To learn more about Barnes v. Unum Life Insurance Company of America, see more.

Mistick v. Unum Life Insurance Company of America
No. 19 CV 190, 2020 WL 13442144 (E.D. Tenn. 2020)

We brought suit against Unum Life Insurance Company because our client’s long-term disability benefits were wrongly terminated.

Our client was covered by her employer’s long-term disability plan. Unum paid our client two years of LTD benefits under the “own occupation” definition in the plan, agreeing she was “limited to performing the material and substantial duties of your regular occupation due to your sickness or injury” and had at least a 20% loss of earnings.  However, Unum’s policy included a  change in its definition of “disabled” once two years of benefits were paid to an “any gainful occupation” provision, requiring our client to prove she was “unable to perform the duties of any gainful occupation for which you are reasonably fitted by education, training or experience.” Mistick, 2020 WL 13442144, at 1.

Unum stopped paying our client benefits after two years, claimed that our client was not disabled.  Despite having paid our client for being unable to do her own occupation for the last two years, when the definition in the policy changed to the “any gainful occupation” definition, Unum found our client was “able to perform the duties of [her] regular occupation on a full-time sustained basis.” Id., at 3.

To learn more about Mistick v Unum, see more.

ERISA does not always apply when an insurance company claims it gave a discount based on where the person worked:

Gooden v. Unum Life Insurance Company of America
181 F.Supp.3d 465 (E.D. Tenn. 2016)

We stopped Unum from winning its argument that ERISA should apply to our client’s case.  Unum wanted ERISA to apply because the rules under ERISA are usually better for an insurance company and if ERISA applied, Unum could force the case to be heard in federal court.  We won the argument, convincing the court that ERISA did not apply and the case should be sent back to state court.

Unum claimed that ERISA applied to our client’s policy, claiming the policy was offered through work, so it was an employee benefit, not a true individual policy.  Unum argued that because several employees who worked with our client paid for their insurance from a payroll deduction and Unum gave them a discount, that the insurance became an ERISA employee benefit.

The court disagreed with Unum that this turned the policy into an ERISA employee benefit because the employer itself did not offer the policy, nor did the employer negotiate the discount.  Because the discount was negotiated directly with the employees, not the employer, ERISA did not apply.

To learn more about Gooden v. Unum Life Insurance Company of America, see more.

ERISA plan documents, penalties under ERISA § 502(c) for a plan administrator’s failure to provide plan documents, eligibility for life insurance for someone who is disabled under a life waiver of premium (LWOP) provision:

Harris-Frye v. United of Omaha Life Insurance Company
 No. 1:14-CV-72, 2015 WL 5562193 (E.D. Tenn. June 1, 2015) (Report and Recommendation)
2015 WL 5562196 (E.D. Tenn. Sept. 21, 2015) (final order)

A carpenter had life insurance through his union.  Under the plan, union members had coverage while working and for some time between jobs.  Union members could “bank” up to 90 days of coverage when not working.

The life insurance policy also included a life-waiver of premium (LWOP) provision, allowing someone to keep the life insurance in place if he or she became disabled while covered under the policy.

When our client’s father got sick and passed away after he had been out of work for some time, we tried to find out the exact rules and to determine if her father was covered under the rules or if we could prove he was disabled, so that when he passed away the coverage was in place.

United of Omaha ultimately denied his benefits, saying he had to be disabled when he stopped working, not when his “banked” coverage ended.  The court rejected this reasoning, and the claim was sent back to United of Omaha to properly consider whether he was disabled at the time coverage ended under the rules controlling the policy.

Along the way, while we tried to find the plan rules for our client, we wrote several letters to the union asking for the life insurance policy and the plan documents that explained eligibility and coverage.  The union only responded to one letter with only a few pages of documents and did not provide the life insurance policy or any official master “plan document” until after the case was in court.

Under ERISA § 502(c), when a plan administrator, like the Carpenter’s Union Board of Trustees, fails to provide plan documents within 30 days of a written request, the plan administrator can be penalized up to $110 per day, and the penalties are paid to the plan participant or beneficiary (like our client) who requests the documents.  Because the union failed to respond adequately to our requests and did not provide the life insurance policy or master plan document until the case was in litigation, the court ultimately awarded $74,140 in penalties for failure to provide plan documents under ERISA § 502(c).

To learn more about Harris-Frye v. United of Omaha Life Insurance Company, see more.

LINA was unreasonable, and the court overturned the denial of benefits.  LINA should have had the claimant examined before rejecting a treating doctor’s opinion or making credibility determinations.  LINA was unreasonable to tell the claimant to file for social security but then to fail to get a copy of the decision and to ignore the finding by SSA.  LINA was also unreasonable to deny benefits for someone they found disabled without meaningful evidence of improvement:

Holt v. Life Insurance Company of North America
No. 1:13-CV-339, 2015 WL 1243529 (E.D. Tenn. March 18, 2015)

Our client, an engineering and construction project administrator, suffered from a medical condition that caused disabling pain and fatigue. The Life Insurance Company of North America (LINA) agreed she was disabled for about 18 months but then terminated her long term disability (“LTD”) benefits saying she had improved.

Disagreeing with LINA, the former project administrator hired our firm.  We appealed the denial under the appeal procedures in the policy, but LINA refused to change the decision.  We then sued LINA on behalf of our client under ERISA, the Employee Retirement Income Security Act of 1974.  ERISA applied because the LTD benefit were offered at work.

Once in court, we submitted briefs arguing that LINA’s decision to cut off the benefits was arbitrary and capricious.  (This is the test in many cases under ERISA; it means we had to prove LINA’s decision was not only wrong but was unreasonable).

We explained that more than one of our client’s doctors said that her condition caused restrictions and limitations that precluded her from working.  LINA was wrong to terminate her benefits based on a nurse case manager’s (not a doctor’s) report.  We also argued that it looked like LINA relied on minor indications in the record that LINA interpreted to show signs of improvement despite the treating doctors never deviating from their opinion that she was disabled.

After we appealed and submitted additional information from Ms. Holt’s doctors, LINA relied on the opinion of a rheumatologist LINA hired who never examined our client.  The doctor LINA hired told LINA wnt so far as to say there were not any restrictions or limitations. We argued LINA should not rely on a doctor who never examined the person, especially when the doctor’s opinion was so unreasonable it said the person had no limitations.

The court ultimately agreed with us that LINA’s decision was unreasonable (technically called “arbitrary and capricious”) in the way it considered the claim. The court determined that LINA unreasonably relied on a non-treating doctor when the claimant had a medical condition that required a credibility determination.  Another reason the court found LINA to be unreasonable was for relying on the opinion of the doctor LINA hired when the opinion was so bad it “lacked substantive analysis.” The court also explained that the LINA doctor’s opinion “was grossly at odds with the treatment records” and treating doctor opinions.

The court additionally explained that LINA’s decision was unreasonable because it failed to substantively address the social security decision despite having required the claimant to apply for social security disability and knowing that she had won her social security disability benefits. LINA should have meaningfully considered the social security decision despite the fact the social security decision was not in the file; LINA knew about it and should have tried to get it to consider it.

To learn more about Holt v. Life Insurance Company of North America, see more.

A plan administrator who provided false information regarding coverage breached its fiduciary duty, and the court ordered it to pay our client’s full, expected amount of coverage:

Rainey v. Sun Life Assurance Company of Canada
Order on Remedies, No. 3:13-CV-0612, 2014 WL 7156517 (M.D. Tenn. Dec.15, 2014)
Order adopting R&R, No. 3:13-CV-0612, 2014 WL 4979335 (M.D. Tenn. Oct. 6, 2014)
Report and Recommendation, No. 3:13-CV-0612, 2014 WL 4053389 (M.D. Tenn. Aug. 15, 2014)

Our client was the executor of an estate for his deceased family member. That family member worked part-time and enrolled in life and accidental death and dismemberment coverage through her employer. Under her plan, part-time employees were eligible for less coverage than full-time employees.

The employer, who served as the plan administrator, used a benefits web portal to provide information to participants regarding their coverage. But, despite her status as a part-time employee, the employer classified our client’s loved-one as a full-time employee, which allowed her to enroll in full-time coverage. As a result, the web portal stated that she had more coverage than was normally allowed for part-time employees.

Our client’s loved-one never received the plan information she needed to discover that the coverage was incorrect, so she began paying premiums for the higher level of coverage. When she passed away, the insurance company refused to pay the full amount of coverage listed on the web portal, and stated in her enrollment forms, so we helped our client win the full, expected amount of coverage.

The court held that the employer breached its fiduciary duty to our client’s family member. The employer’s web portal misrepresented her coverage, the misrepresentations materially misled our client’s family member, and she relied upon those misrepresentations to her detriment. For these reasons, the court accepted our request for full payment of the expected benefits.

To learn more about Rainey v. Sun Life Assurance Company of Canada, see more.

Unum wrongfully tried to apply a shorter appeal deadline than was in the plan:

Knight v. Provident Life and Accident Insurance Company
not reported in F. Supp. 3d (2014), 2014 WL 1280278

Unum paid long term disability (LTD) benefits for almost 12 years before denying benefits in 2012.  When Unum denied the claim, Unum gave 90 days to appeal.  Our client’s previous attorney failed to appeal within 90 days.  The client left his previous attorney after that and hired us.  We filed an appeal after we took over the case, which was after about 123 days from the denial. This issue in this case was whether this appeal was on time or late.

Because our client became disabled before January 1, 2002, Unum argued that an older version of the ERISA claims regulations applied.  Under those regulations, Unum only had to allow 60 days to appeal; they argued they gave even more time by giving 90 days.  The Department of Labor issued new claims regulations while Unum was paying this claim that allowed for 180 days to appeal, but those regulations were only effective to claims filed after January 1, 2002, so arguably did not apply to this claim.

However, while benefits were being paid, the LTD benefits plan and insurance policy was updated to reflect the new claims regulations, so the LTD plan said someone who was denied had 180 days to appeal.  The court agreed with us that because that was the plan provision in place when the claim was denied, that plan provision controlled, so Unum should have given 180 days to appeal.  Because the appeal was filed in 123 days, less than the 180 days under the plan, the appeal was timely.  The court denied Unum’s motion to uphold its denial, granted out motion, and ordered Unum to consider the appeal timely filed.

To learn more about Knight v. Provident Life and Accident Insurance Company, see more.

Aetna initially refused to provide us with the information we requested regarding their decision-making process, but the court ordered it to comply with our request:

Kasko v. Aetna Life Insurance Company
33 F. Supp. 3d 782 (E.D. Ky. 2014))

Our client became disabled and requested long term disability (LTD) benefits under her Aetna policy, but Aetna, the plan administrator, denied her claim. We sued on our client’s behalf, arguing among other things that Aetna’s denial was influenced by a conflict of interest and that the doctors reviewing our client’s claim were biased.

In order to make these arguments, we asked Aetna to answer basic questions and provide us with some relevant information regarding its relationship with the reviewing doctors and its review process in general. Aetna challenged our requests, so we asked the court to order Aetna to comply.

The court agreed with us and granted our motion to compel discovery. It rejected Aetna’s argument that the information we sought was irrelevant and that it would be “unduly burdensome” for Aetna to provide us the information. Ultimately, the court ordered Aetna to comply with our requests on the condition that our firm only use the information for litigating the case.

To learn more about Kasko v. Aetna Life Insurance Company, see more.

Hartford arbitrarily and capriciously terminated our client’s benefits, so the court of appeals reinstated benefits, forcing Hartford to begin paying our client again:

Neaton v. Hartford Life & Accident Insurance Company
517 F. App’x 475 (6th Cir. 2013)

Our client began receiving long-term disability benefits after working for his employer for over 30 years. He had been struggling with a condition that forced him to undergo painful treatments and frequently caused him to be absent from work in order to recover. Hartford initially approved his claim, recognizing that our client’s work environment exacerbated his condition and made recovery difficult following treatments.

Despite its initial approval, Hartford decided to review our client’s claim once more. It asked for more information from our client, his treating physician, and his employer. Hartford hired a vocational expert to determine how much absenteeism was tolerable for someone in our client’s job and also employed its own physician to assess the severity of our client’s condition and how his work environment might impede his recovery. Our client’s treating doctor disagreed with the Hartford-employed physician’s conclusions, particularly with the physician’s statement that our client’s work environment did not meaningfully contribute to his condition.

After concluding its review, Hartford decided to terminate our client’s benefits, which it had already been paying for over six months. We sued Hartford on our client’s behalf. The district court agreed with Hartford, so we appealed that decision and successfully convinced the court of appeals that Hartford’s decision to terminate our client’s benefits was arbitrary and capricious. To remedy Hartford’s breach, the court of appeals reinstated our client’s benefits, forcing Hartford to begin paying again and also to pay for benefits “wrongfully withheld” from our client while we litigated the case.

To learn more about Neaton v. Hartford Life & Accident Insurance Company, see more.

Insurance companies should not rely on doctors who don’t conduct an exam, who don’t explain the reasons for their opinions, and who don’t address inconsistencies:

Bailey v. United of Omaha Life Insurance Company
938 F. Supp. 2d 736 (W.D. Tenn. 2013)

After paying short-term disability (“STD”) benefits for the full time available under the STD plan, United of Omaha denied the claim for long-term (“LTD”) benefits, claiming the claimant’s restrictions and limitations did not qualify for benefits under the plan.  We sued, and the court reviewed under the common arbitrary and capricious standard of review, which means the insurance company can win, even if they are wrong, but reasonable.

United of Omaha had the medical records reviewed by a doctor during the STD portion of her claim and a “case management nurse” at each of the two levels of her LTD claim, all of whom said the claimant could do her work.  United of Omaha relied on those opinions to deny the claim.

The court considered United of Omaha’s conflict of interest (as it is the company that would pay benefit and would also decide if the claimant was entitled to the benefits) as a factor in whether the insurance company was reasonable.

The court found United of Omaha acted unreasonably by relying on the file reviews it obtained.  United of Omaha had failed to exercise its right to conduct a physical examination.  The insurance company should not have relied on the file reviewer’s reports that contained both conclusory statements that were not supported by evidence and did not contain a full explanation of their findings.  The court remanded the claim to United of Omaha to conduct a fair evaluation of its merits.

To learn more about Bailey v. United of Omaha Life Insurance Company, see more.

Pain can be disabling.  An insurance company should not reject a disability caused by pain because pain cannot be objectively measured.  Insurance companies should not rely on file-reviewing doctors who did not examine the claimant or talk to the treating doctors:

Edwards v. Lincoln National Life Insurance Company
2012 WL 1902396, (M.D. Tenn. May 24, 2012)

Our client suffered from conditions that primarily caused pain and are difficult to measure using medical tests.  Lincoln National denied her long term disability (“LTD”) benefits because the insurance company found that the medical records did not contain objective evidence of total disability based on the opinions of Lincoln National’s own consultants who reviewed the medical records but did not examine the claimant.

The court agreed with our arguments and found that Lincoln National was arbitrary and capricious because the insurance company relied on its own consultants over the opinions of the physicians who treated the claimant. Edwards v. Lincoln Nat. Life Ins. Co., 2012 WL 1902396, at *1 (M.D. Tenn. May 25, 2012). Also, because the claimant’s medical condition was disabling mostly because it caused pain, Lincoln National’s decision to deny benefits due to a lack of objective medical evidence to measure her disability was arbitrary and capricious.  Id., at 14.

To learn more about Edwards v. Lincoln National Life Insurance Company, see more.

The court ordered Provident to provide us with information regarding its decision-making process, which we requested in order to show that its handling of our client’s claim was biased:

Mulligan v. Provident Life and Accident Insurance Company
271 F.R.D. 584 (E.D. Tenn. 2011)

Provident denied our client benefits, so we sued on our client’s behalf. In order to argue our client’s case, we requested information from Provident regarding its decision-making process and handling of our client’s claim. Provident refused to produce that information.

We asked the court to order Provident to comply, and after reviewing our arguments, the court instructed Provident to provide us more information. Specifically, Provident had to provide us with any “monthly trend reports” that Provident employees had access to while deciding our client’s claim. The court also agreed with us that for certain documents Provident agreed to produce, we were not required to return or destroy them at the end of this case but instead could use them in later cases for limited purposes.

To learn more about Mulligan v. Provident Life and Accident Insurance Company, see more.

Discovery is limited in ERISA benefits cases; a plaintiff may obtain narrowly tailored discovery into the an alleged conflict of interest without making an initial showing:

Kinsler v. Lincoln National Life Insurance Company
660 F. Supp. 2d 830 (M.D. Tenn. 2009).

The Court granted our motion to be allowed to take discovery into the insurance company’s conflict of interest and held that a plaintiff is not required to make an initial threshold showing of bias in order to pursue such discovery where the plaintiff has alleged a conflict of interest and the discovery requested is narrowly tailored to that issue.

To learn more about Kinsler v. Lincoln National Life Insurance Company, see more.

Court ordered GGL to pay our client’s claim for benefits after holding that GGL’s review was arbitrary and capricious:

Goetz v. Greater Georgia Life Insurance Company
649 F. Supp. 2d 802 (E.D. Tenn. 2009)

Our client suffered a physical injury that left him disabled and unable to serve in his previous C-suite position. His insurance company, Greater Georgia Life (GGL), denied his request for disability benefits, claiming that our client’s disability was caused by a pre-existing condition that GGL excluded from coverage.

We successfully argued that our client’s disability was not from a pre-existing condition and that GGL’s denial was arbitrary and capricious. Its denial was based upon little evidence, and its explanation was unreasonable. As such, the court ruled that GGL’s decision was arbitrary and capricious. Then, instead of remanding to GGL to review the claim once more, the court decided to award our client benefits since he was “clearly entitled” to them.

To learn more about Goetz v. Greater Georgia Life Insurance Company, see more.

MetLife arbitrarily and capriciously denied our client’s claim for benefits three times, so the court ordered MetLife to reinstate her benefits and pay us attorneys’ fees:

Satterwhite v. Metropolitan Life Insurance Company
803 F. Supp. 2d 803
2008 U.S. Dist. LEXIS 112854
2008 WL 2952473
2007 WL 2746886

Our client became disabled and started receiving benefits under her MetLife policy. After a few years, however, MetLife decided to terminate her benefits because it believed she was no longer sufficiently disabled. Our client appealed that decision, but MetLife denied her again, so we sued MetLife on our client’s behalf.

The court agreed with us that MetLife’s denial decisions were arbitrary and capricious. MetLife’s conclusions did not align with the evidence in our client’s file, and instead, MetLife relied upon weak evidence from its hired physician who never examined our client. As a result, the court ordered MetLife to review our client’s claim again, but this time, it had to use a fair and reasoned review process and seek out appropriate medical information to support its conclusions.

We requested attorney’s fees for the work we did to get our client this new review process. MetLife objected, but the court agreed with us and ordered MetLife to pay us $16,933.00, the full amount of our request.

As required by the court, MetLife reviewed our client’s claim again. It approved her claim at first, but then a few months later, terminated her benefits once more. We sued MetLife again, and the court agreed with us that MetLife’s newest decision was arbitrary and capricious.

Principally, the court faulted MetLife for failing to get an independent medical examination of our client, despite the fact that the previous court had strongly suggested that MetLife do so. It also found that MetLife again handpicked evidence that supported denial, while ignoring all of the evidence that supported the existence of our client’s disability. For those reasons and others, the court awarded our client benefits.

To learn more about Satterwhite v. Metropolitan Life Insurance Company, see more.

The plan administrator reviewing our client’s claim for disability benefits acted arbitrarily and capriciously when it denied our client’s claim, and as a result, our client’s employer had to pay his disability benefits and cover our attorney’s fees:

Smith v. Bayer Corporation Long Term Disability Plan
No. 3:04-CV-128, 2009 WL 676774 (E.D. Tenn. Mar. 11, 2009)
275 F. App’x 495 (6th Cir. 2008) (Unpublished)

Our client had disability insurance through his employer. He became disabled and applied for long-term disability benefits under his plan. The third-party administrator used by our client’s employer denied our client’s request and subsequently upheld its decision on appeal. We sued following these decisions and the court remanded our client’s case back to the plan administrator for another review process. Again, the plan administrator upheld its denial decision, so we sued once more.

This time, the court simply concluded that the denial decision was arbitrary and capricious. The plan administrator used by our client’s employer conducted an unreasonable decision-making process. It found that our client could work in his previous position based only upon opinions from reviewers who had never examined our client in-person, even though our client’s disability was one that generally requires in-person examination to accurately assess. Thus, the court ordered our client’s employer to pay our client the benefits he deserved.

Our client’s employer appealed this decision, but the Sixth Circuit Court of Appeals agreed with us and the lower court that the denial decision was in fact arbitrary and capricious. Specifically, the Sixth Circuit found the employer’s refusal to pay benefits to be unreasonable during the first six months after our client became eligible for long-term disability benefits and also during the time period in which our client began working at a retail job. For the time period between the first six months and the start of our client’s retail job, the Sixth Circuit remanded the case back to the lower court for more review.

Based on our work in this case, we requested that the lower court order our client’s employer to pay our attorney’s fees. The court agreed with us and ordered the employer to pay $13,520.00, the full amount of our request.

To learn more about Smith v. Bayer Corporation Long Term Disability Plan, see more.

Our client’s employer arbitrarily and capriciously denied his claim for long-term disability benefits, and we sued, ultimately convincing the court to order the employer to provide our client a fair review process:

Molodetskiy v. Nortel Networks Short-Term & Long-Term Disability Plan
594 F. Supp. 2d 870 (M.D. Tenn. 2009)

Our client had disability coverage through his employer, and after almost three years of employment, he became disabled and had to stop working. His employer approved him for short-term disability benefits and later, for long-term disability benefits. Despite the employer’s initial belief that our client was disabled, the employer changed its mind and later terminated his long-term disability benefits.

We appealed the denial decision, but the plan administrator upheld its denial. Again, we appealed, and this time, a review committee from our client’s employer reviewed his claim. We pointed out the flaws in the plan administrator’s decision, but the employer’s review committee affirmed the plan administrator’s denial decision. After that, we sued under the Employee Retirement Income Security Act, arguing that the decision to deny our client long-term disability benefits was arbitrary and capricious.

The court agreed with us, holding that two conflicts of interest existed on behalf of the employer and that its decision against our client was arbitrary and capricious. As a result, the court instructed the insurance plan to undertake another review of our client’s claim, this time using a reasonable decision-making process.

To learn more about Molodetskiy v. Nortel Networks Short-Term & Long-Term Disability Plan, see more.

Court-awarded attorney’s fees:

Cooper v. Life Insurance Company of North America
United States District Court for the Eastern District of Tennessee (2008)

After we won this case in the Sixth Circuit, the Court of Appeals remanded this case to the District Court to award retroactive benefits and other relief as appropriate. The District Court then granted our petition for $42,815.00 in attorney’s fees and $250.00 for reimbursement of the client’s court-filing fee.

To learn more about Cooper v. Life Insurance Company of North America, see more.

Insurers should not rely on file reviewers who do not examine the claimant, especially where credibility determinations are needed.  When a court awards benefits, that includes all the benefits due under the plan and putting the person in the position she would have been in if benefits had been paid from the beginning:

Bradford v. Metropolitan Life Insurance Company
No. 3:05-CV-240, 2007 WL 956640 (2007) (unreported)

514 F.Supp.2d 1024 (E.D.Tenn. 2007)

There are two important orders from the court in this case.  In Bradford v. Metro. Life Ins. Co., No. 3:05-CV-240, 2007 WL 956640, at *12 (E.D. Tenn. Mar. 29, 2007), the court found that our client was “totally disabled as defined by the Plan and that MetLife’s conclusion that Plaintiff is not disabled was arbitrary and capricious.” After ruling in our client’s favor, the court then considered more briefing about what benefits were due.  The court issued another decision, Bradford v. Metro. Life Ins. Co., 514 F. Supp. 2d 1024 (E.D. Tenn. 2007), explaining that our client was entitled to all the benefits she should have received when found disabled under the plan.

In the decision finding our client disabled, the court explained that our client had been paid all her short term disability (STD) benefits, but that MetLife denied her long term disability (LTD) benefits from the very beginning.  MetLife relied on several doctors who reviewed the claimant’s medical records, who in turn said the claimant had presented “insufficient objective evidence to support a finding of total disability,” or that her “pain complaints were out of proportion to her pathology or diagnosis.” Bradford, 2007 WL 956640, at *10.

The court set out multiple reasons MetLife’s decision-making was wrong. MetLife had the ability to have the claimant examined, but chose not to, instead relying entirely on doctors who only reviewed medical records.  The court further found that MetLife’s choice to rely on file-reviewing doctors was wrong because the doctors offered opinions about the claimant’s pain and credibility.  The doctors also failed to consider the effects of her medications and of her other medical conditions other than the ones they were asked about.  MetLife also erred by relying solely on their own doctors without properly considering the opinions of the treating doctors.

After the first opinion finding our client disabled, we went back before the court to clarify just what benefits she was entitled to.  In addition to granting pre-judgment interest on the benefits she was owed, the court also ordered her to be awarded the other collateral benefits that should be provided to someone who is being paid LTD benefits under plan, including reinstatement of her life insurance at her pre-disability level, the option to reinstate her eligibility for a normal pension retirement, and reimbursement of life insurance premiums she paid after becoming disabled.

To learn more about Bradford v. Metropolitan Life Insurance Company, see more.

If the administrator’s decision is arbitrary and capricious, benefits should be awarded unless the “adequacy of claimant’s proof is reasonably debatable:”

Cooper v. Life Insurance Company of North America
486 F.3d 157 (6th Cir. 2007)

The Court of Appeals for the Sixth Circuit agreed with us that the Life insurance Company of North America (LINA) wrongfully denied our client benefits, that LINA’s decision was arbitrary and capricious, and that our client should be paid.  LINA improperly rejected the medical records and opinions from several of the claimant’s treating doctors.  LINA also ignored the opinion from the doctor the Social Security Administration hired to examine her.  Even one of the doctors hired by LINA to review the records agreed that the claimant had restrictions to working no more than two to three hours per day, but also made other contradictory findings.  The second file-reviewing doctor hired by LINA “failed to provide a reasonable basis for denying the claim and … compounded errors” made in the first report. Cooper v. Life Ins. Co. of N. Am., 486 F.3d 157, 169 (6th Cir. 2007).

Once the Court of Appeals determined that LINA denied the claimant arbitrarily and capriciously, the court addressed the appropriate remedy.  In discussing whether the court should remand the case to the insurance company to reconsider or whether the court should award benefits, the court explained that insurance companies should not get “two bites at the proverbial apple;” the insurance company should “properly and fairly evaluate the claim the first time around.” Id, at 172. The Court of Appeals set out the rule that courts should only remand to give the insurance company another chance “where the adequacy of claimant’s proof is reasonably debatable.” Id.

To learn more about Cooper v. Life Insurance Company of North America, see more.

Insurance companies should not reject a claim just because some of the person’s complaints are “subjective.” Insurance companies should not rely on non-examining doctors to evaluate someone’s credibility, especially where they have the right to have the person examined and choose not to.  Insurance companies should adequately consider treating doctors’ opinions:

Platt v. Walgreen Income Protection Plan for Store Managers
455 F.Supp.2d 734 (M.D. Tenn. 2006)

No. 3:05-0162, 2006 WL 3694580 (M.D.Tenn. Dec. 14, 2006)

Our client had a MetLife long term disability (LTD) policy at work. When she became disabled, MetLife paid benefits for a short time but then decided to stop paying.  She appealed, hired us, and we eventually sued on her behalf.

Because the LTD benefits were offered at work, this case fell under ERISA, the Employee Retirement Income Security Act of 1974. MetLife had included language in its policy saying it had discretion so that under ERISA, the court reviewed the case under an “arbitrary and capricious” standard of review; this means that the insurance company only has to be reasonable, even if they are wrong. Platt v. Walgreen Income Prot. Plan for Store Managers, 455 F. Supp. 2d 734, 743 (M.D. Tenn. 2006).

Despite agreeing with MetLife that the court did not have to consider information submitted to MetLife after our client had used up all her appeals, the court still found that MetLife’s decision-making process was so wrong that it was arbitrary and capricious and overturned the denial. Id., at 747.

MetLife argued that our client’s records did not have “objective indicators that” our client’s “medical condition preclude[d] [our client] from engaging in ‘any gainful occupation,’ ” which was the test under the policy.  Id, at 744.  MetLife relied on cases saying that they could deny the claim because the claimant made “subjective complaints.”  The court rejected that argument, pointing out that, in the cases, MetLife attempted to rely on, the person did not even have a firm diagnosis of the condition, while in this case, two doctors confirmed the diagnoses.

The court then explained that the important consideration was whether MetLife was reasonable to reject the opinion of our client’s treating physician in favor of two doctors MetLife hired to review the medical records. Id, at 744. “A Claims Administrator may not arbitrarily refuse to credit a claimant’s reliable evidence, including the opinions of a treating physician.” Platt v. Walgreen Income Prot. Plan for Store Managers, 455 F. Supp. 2d 734, 745 (M.D. Tenn. 2006), citing Black & Decker Disability Plan v. Nord, 538 U.S. at 834, 123 S.Ct. 1965 and Smith v. Continental Cas. Co., 450 F.3d 253, 262 (6th Cir.2006). “And the consulting physicians hired by the Claims Administrator to review the file may not make credibility determinations concerning the claimant’s subjective complaints without the benefit of a physical examination.” Platt, 455 F. Supp. 2d at 745, citing Smith, 450 F.3d at 263.  Therefore, “under Nord, MetLife was not required to give deference to [the treating doctor’s] opinion over the opinions of its own consulting physicians. But MetLife’s consultants were not free to discredit Plaintiff’s subjective complaints of pain or its impact on her physical capacity without a physical examination.”  Platt, 455 F. Supp. 2d at 745, citing, Smith, 450 F.3d at 262–263.

MetLife’s decision to rely on its on non-examining doctors’ opinions about the claimant’s complaints was especially wrong because MetLife had the right to have the claimant examined by a doctor under the rules in the policy.  The refusal to get such an exam “supports the conclusion that MetLife’s decision to deny benefits was arbitrary and capricious, particularly when MetLife’ s conflict of interest is taken into account.” Id., at 746–47.

The court ultimately agreed with us and concluded that MetLife had acted arbitrarily and capriciously in denying the claim.  MetLife should not have rejected our client’s complaints simply because she made subjective complaints, should not have relied on their own doctors without properly considering the treating doctors, should not have relied on their doctors opinion as to the claimants credibility, especially when the policy allowed the claimant to be examined by a doctor of their choice.  While the court said MetLife’s decision was wrong, the court did not award benefits but remanded to MetLife to reconsider and to consider the evidence it did not look at before.

To learn more about Platt v. Walgreen Income Protection Plan for Store Managers (and MetLife), see more.

Nissan, as Plan Administrator of our client’s LTD plan, ordered to pay a penalty for failing to turn over plan document after we requested them:

Dies v. Provident Life & Accident Insurance Company
No. 3:04-CV-0113, 2006 WL 208878; 37 Employee Benefits Cas. (BNA) 2364, (M.D.Tenn. Jan. 25, 2006)

We sued Provident, a Unum company, for failing to pay our client’s benefits.  We also sued Nissan, her employer that offered the long term disability (LTD) benefits, because Nissan refused to provide us copies of our client’s plan documents.

After Provident denied our client’s benefits and she hired us to help her, we asked her employer, Nissan, for a copy of her long term disability policy.  Even though we wrote several letters, Nissan failed to provide us a copy of the policy.  After we appealed the denial of our client’s benefits and Unum refused to pay, we sued both for the benefits and for Nissan’s failure to turn over plan documents.  In our lawsuit we pointed out to the court that Nissan still had not provided the documents.

We sued Nissan for failing to provide the documents because ERISA also has a rule that the plan administrator of an employee benefit plan (usually the employer) has to provide copies of any plan documents, like an LTD policy, within 30 days of a written request.  If the plan administrator fails to provide the document within 30 days, a court can make the plan administrator pay up to $110 per day for any day after 30 days the documents are not provided.

As this case went on, Provident and our client settled the claim for benefits, but we continued to pursue the claim for penalties for the failure to provide plan documents. The court awarded our client $28,650 in penalties for Nissan’s failure to provide the plan documents.

To learn more about Dies v. Provident Life & Accident Insurance Company, see more.

Discovery in an ERISA case permitted into an insurance company’s bias, conflict of interests, and unfair claims handling practices:

Bennett v. Unum Life Insurance Company of America
321 F. Supp. 2d 925 (E.D. Tenn. 2004)

This order was one of the first rulings in an ERISA case that a court agreed to order an insurance company to give up information about its unfair claims’ practices.

When a case is in court, normally parties learn information about the other side during a process called “discovery.,” But in ERISA cases, courts have limited discovery, saying parties can only get the information in the claim file that was relied on or submitted to the insurance company.  We successfully argued that there should be an exception to the “no discovery” rule when attorneys for disabled claimants are seeking information about the way insurance companies like Unum have internal policies and procedures that encourage their claims handlers to deny claims.

Prior to this case, the Supreme Court and the Court of Appeals for the Sixth Circuit had suggested that discovery into the insurance company’s bias and conflict of interest might be permitted.  This was one of the first cases to address what an attorney has to show in order to get this type of discovery; it was also one of the first cases to actually get an order allowing for discovery of information into the biased procedures of an insurance company.

One question was whether courts would allow this discovery just by saying the insurance company was biased or whether attorneys would need to show the court some information to make the discovery reasonable.  In this case, the court said that we needed to show some information that suggested the discovery was reasonable.  The court then held we had provided enough information to show the discovery was reasonable and ordered Unum to answer some discovery into the company’s biased claims handling.  (Some later cases have held that such initial showing is not required, but other courts still require an initial showing.)

To learn more about Bennett v. Unum Life Insurance Company of America, see more.

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