Legal Summary: Holt v. Life Insurance Company of North America

No. 1:13-CV-339, 2015 WL 1243529 (E.D. Tenn. Mar. 18, 2015).

Our client was covered under a LINA LTD policy provided by her employer.  When she became disabled, LINA agreed she was disabled for 18 months then terminated her benefits because she had supposedly improved. We appealed this denial after she hired us.  LINA refused to change their decision and denied the claim again.  We then filed this lawsuit to help our client get the LTD benefits reinstated.  Holt v. Life Ins. Co. of America, No. 1:13-CV-339, 2015 WL 1243529, at 1 (E.D. Tenn. Mar. 18, 2015).

We explained to the court that two rheumatologists and our client’s own primary care physician examined her, confirmed her diagnosis, and opined she could not return to work. Id. at 2.  LINA originally approved her long term disability claim, but LINA then viewed her medical records as showing improvement so LINA terminated her benefits. Id. at 2–3.  LINA read her doctor’s notes of minor improvements as an indication that she was now able to work again. Id. at 3.

When we appealed before taking the case to court, we had submitted an additional opinion from her treating doctor stating her limitations, which conflicted with the physical abilities necessary to perform in Ms. Holt’s profession. Id. LINA hired a rheumatologist to evaluate Ms. Holt’s claim based only on her medical file—not on any personal examination of Ms. Holt. Id. He concluded that the medical records gave no indications from a “rheumatology standpoint” that our client had any such restrictions or limitations that would disable her from working. Id. Based on this opinion, LINA affirmed its denial of our client’s claim. Id. We then sued.

Because the policy gave discretion to the administrator in construing the plan and determining eligibility, the court reviewed LINA’s decision under an arbitrary and capricious standard. Id. at 4. This standard looks at whether the administrator’s determination and decision-making process was reasonable, given the information in front of the administrator at the time of its determination. Id.

The court agreed with our argument that LINA was unreasonable for relying on the doctor they chose who only reviewed medical records. Id. at 5. One reason LINA was unreasonable for relying on a doctor who only reviewed medical records is that LINA had the option to have the claimant be examined in person by a physician of the insurance company’s choosing (something insurance companies call an “independent medical examination,” or “IME”) but instead relied only on a medical file review. Id. at 5. The court explained that, although this choice is not determinative of whether an administrator acted arbitrarily and capriciously, it weighs against LINA; relying on a record reviewing doctor when the insurance company could have obtained an IME “raise[s] questions about the thoroughness and accuracy of the benefits determination.” Id, citing Calvert v. Firstar Fin., Inc., 409 F.3d 286, 2953 (6th Cir.2005).

Another reason the court held that it was unreasonable for LINA to rely only on a record reviewing doctor was that the claimant suffered from a medical condition that included subjective symptoms of pain and fatigue and the file-reviewing doctor made a credibility determination without ever seeing the person. Holt, 2015 WL 1243529, at 5.  The non-examining, file reviewing doctor, made the credibility determination that her “subjective complaints” were “out of proportion to the physical findings.”  Id.  The court did not like the fact LINA relied on that opinion, making a credibility determination based only on a record review “increase[d] the Court’s concern with LINA’s decision to rely only on a non-examining file reviewer.” Id.

Yet another reason the court explained that LINA acted unreasonably in relying on the non-examining, file reviewing doctor is that the doctor went so far as to say the records did not “support any restrictions and limitations.” Id. at 6 (emphasis added by the court). The court explained that, despite summarizing the other doctors’ findings that supported restrictions and limitations, the LINA file-reviewing doctor did “not articulate why the record fails to support ‘any restrictions and limitations.’ ” Id. (emphasis added by the court).

In addition to the concerns with LINA relying on a file reviewing doctor, another reason the court found LINA’s decision unreasonable was LINA’s failure to give meaningful consideration to the finding of disability by the Social Security Administration.  The court explained that if the insurance company requires the claimant to file for social security disability, it is improper for the insurance company to ignore then a favorable decision by the Social Security Administration finding the person disabled.  The insurance company mist conducts some meaningful analysis of the social security decision.  The insurance company must meaningfully consider a favorable social security decision even when the claimant failed to submit a copy of the social security decision if the insurance company was aware of it and had permission to obtain it on its own.  If the insurance company is aware of the favorable decision, the insurance company must consider it.  Id., at 6 and 8 The court explained:

The Sixth Circuit has held that “an ERISA plan administrator is not bound by an SSA disability determination when reviewing a claim for benefits under an ERISA plan.” Whitaker v. Hartford Life & Accident Ins. Co., 121 F. App’x 86, 88 (6th Cir.2005); see also Calvert, 409 F.3d at 293 (noting “the incongruity of binding an ERISA plan administrator to the SSA’s disability determination, when the SSA-but not the ERISA administrator-is bound by law to accord special deference to a claimant’s treating physician”). However, it is improper for a plan administrator to require a claimant to file a SSDI claim (as occurred here), but then ignore a SSDI award in its own analysis. See Glenn v. MetLife, 461 F.3d 660, 669 (6th Cir.2006); Calvert, 409 F.3d at 295 (6th Cir.2005). Thus the fact that LINA stated that it “considered” the successful SSDI claim yet provided no substantive explanation of why the plan disagreed with it2 lends support to Holt’s claim that LINA’s determination was unreasonable.

Id., at 6.  In footnote 2, in the quote above, the court explained what analysis LINA provided that was not good enough: “LINA merely noted that ‘the criteria used by the Social Security Administration (SSA) may differ from the requirements of the policy under which your client is covered.’ ” Id., at n. 2. The court ultimately concluded that because “LINA never substantively addressed the SSDI award despite having required [the claimant] to apply for SSDI benefits and having acknowledged the award” was a factor contributing to the conclusion that LINA’s decision was arbitrary and capricious. Id. at 8.

Ultimately, the court agreed with us that LINA was arbitrary and capricious in its determination that our client was not disabled. Id. at 8. The court concluded its opinion, setting out again the factors that supported this finding:

(1) [The non-examining doctor LINA hired and relied on] was a non-treating reviewer dealing with the inherently subjective matter of [a medical condition which causes pain and fatigue], which require credibility determinations; (2) [LINA’s file reviewing doctor’s] opinion lacked substantive analysis; (3) [LINA’s file reviewing doctor’s] conclusion that no restrictions and limitations whatsoever should apply was grossly at odds with treatment records and [The treating doctor’s] opinion; and (4) LINA never substantively addressed the SSDI award despite having required Holt to apply for SSDI benefits and having acknowledged the award.

Id.

Because the court concluded that LINA was arbitrary and capricious in its determination, the court remanded the decision back to LINA for a proper review of her claim. Id. This allowed us to continue fighting for our client’s benefits.

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