BenGlassLaw long-term disability team wins benefits for physical therapist assistant who ceased working due to a multitude of debilitating symptoms
The BenGlassLaw long-term disability team, lead by attorney Damon Miller, won another case in the federal court in Virginia.
The claimant, employed as a Physical Therapist Assistant at Legacy Healthcare Services ceased working due to a multitude of debilitating symptoms including arthralgia (joint pain), back pain, neck pain from cervical herniated discs, fibromyalgia (a chronic condition characterized by widespread musculoskeletal pain, fatigue, and tenderness in localized areas), chronic fatigue, Epstein-Barr virus (a common virus that causes mononucleosis and is associated with certain immune system disorders), IBS (a chronic gastrointestinal disorder characterized by symptoms such as abdominal pain, bloating, and irregular bowel habits), and migraines. Despite the severe impact of these conditions on her ability to perform her job, her initial claim for long-term disability benefits was denied by Reliance Standard.
(Read this article to see how you can win your claim against Reliance Standard.)
Why Reliance Standard Denied The Claim
Reliance Standard’s rationale for the denial was grounded in what they perceived as a lack of sufficient medical evidence to validate the claimant’s continued impairment. They contended that the medical investigations into the claimant’s various diagnoses had inconclusive outcomes, and there were no objective findings that aligned with the severity of symptoms she reported. This stance is a common tactic used by insurers to minimize the payout of claims, often leaving claimants in precarious financial and health situations.
The Response to the Claim Denial
In response, the BenGlassLaw team vigorously contested the denial. The team presented detailed medical opinions from multiple treating physicians, each underscoring the claimant’s inability to engage in not just her previous occupation but any gainful activity at all. The medical professionals described her conditions as severely debilitating and explicitly stated that her symptoms and the side effects of her medications precluded any form of consistent work activity.
Reliance Argued that She Could Work Because She Maintained a Blog
On the other side of the courtroom, Reliance Standard maintained their position by emphasizing the claimant’s ability to perform certain activities like writing and managing a blog. They argued that these activities demonstrated cognitive and physical capacities inconsistent with the claimant’s reported disabilities. However these activities were not only sporadic but also not indicative of the ability to sustain full-time employment, especially in a role as physically demanding as a Physical Therapist Assistant.
Reliance Wanted in Independent Exam, We Said “No Way,” and the Court said We Were Right
In the litigation, one of the arguments presented by Reliance Standard centered on the claimant’s refusal to attend an Independent Medical Examination (IME). Reliance argued that the claimant filed her lawsuit prematurely, which prevented them from conducting the IME that they deemed necessary to properly assess her claim. We have argued in the past that these so-called independent exams are biased.
Reliance Standard highlighted that their request for an IME was a standard procedure meant to obtain an objective assessment of the claimant’s health condition. They contended that the IME was crucial for making an informed decision regarding the claimant’s ongoing eligibility for disability benefits, especially given the disputes over the extent and nature of her disabilities.
This argument by Reliance Standard was part of their broader defense strategy to uphold their decision to deny the disability benefits and to argue against the imposition of a de novo standard of review. They maintained that the claimant’s lawsuit was filed too soon, implying that she had not allowed them the opportunity to adequately address her appeal through all available administrative procedures, including the IME.
The court, however, did not find this argument sufficient to delay or deny the claimant’s rights under ERISA. The court disagreed with Reliance Standard’s assertion, noting that the regulatory deadlines for responding to an appeal were clear and that Reliance’s failure to adhere to these deadlines (independent of the IME issue) meant that the claimant was deemed to have exhausted her administrative remedies, allowing her to pursue legal action.
ERISA’s Timing Requirements For Insurance Companies
Under ERISA (Employee Retirement Income Security Act), there are specific requirements for how plan administrators must respond to a disability appeal. Here’s a breakdown of the key requirements:
Initial Response Timeframe:
- Plan administrators are required to make a decision on an appeal of a denied claim for disability benefits within 45 days after receiving the request for review.
Extension of Time:
- If special circumstances require additional time for processing an appeal, the plan administrator may extend this period for up to an additional 45 days. However, the administrator must notify the claimant before the end of the initial 45-day period, explaining the reasons for the extension and specifying when the plan expects to render a decision.
Notification of Decision:
- If the appeal is denied, the plan must provide a written or electronic notification, which includes:
- Specific reasons for the denial.
- References to the specific plan provisions on which the denial is based.
- A statement that the claimant is entitled to receive, upon request and free of charge, reasonable access to and copies of all documents, records, and other information relevant to the claimant’s claim for benefits.
- A statement describing any voluntary appeal procedures offered by the plan and the claimant’s right to obtain the information about such procedures.
- A statement of the claimant’s right to bring a civil action under Section 502(a) of ERISA.
Requirement for Full and Fair Review:
- The review must be a full and fair assessment of the claim and must take into account all comments, documents, records, and other information submitted by the claimant relating to the claim, without regard to whether such information was submitted or considered in the initial benefit determination.
These requirements ensure that claimants receive a thorough review of their appeals and are kept informed throughout the process, fostering transparency and fairness in the administration of disability benefits under ERISA-regulated plans.
The court also emphasized that an insurer may not unilaterally extend the appeal period by scheduling an IME after the appeal decision deadline has passed. Thus, the court did not accept Reliance Standard’s argument that the claimant’s lawsuit was premature or that her refusal to attend an IME prior to filing the lawsuit was a valid reason for denying her benefits.
The Court also Agreed with BenGlassLaw that The Standard of Review was De Novo
Under ERISA (Employee Retirement Income Security Act of 1974), claimants are typically entitled to a full and fair review of denied claims, which includes timely responses to appeals. Regulations stipulate specific deadlines that plan administrators must adhere to when a claimant files an appeal against a denial of benefits. In this case, Reliance Standard did not issue their appeal decision within the prescribed 45-day period, which can be extended only under specific circumstances involving special conditions that were not met here.
The claimant leveraged this failure to comply with ERISA’s strict timing requirements to assert that the court should adopt a de novo standard of review rather than the more deferential abuse of discretion standard. The de novo review standard does not give weight to the insurance company’s previous decision but instead allows the court to review the case from scratch, independently evaluating the facts and the law.
The argument was grounded in legal precedents and ERISA regulations, which dictate that if a plan administrator fails to adhere to the procedural requirements of ERISA, particularly those concerning the timing of appeal decisions, the claimant is deemed to have exhausted administrative remedies. This procedural misstep allows the court to bypass the usual deference to the administrator’s decision (abuse of discretion review) and assess the case under a de novo review.
This strategic legal argument emphasized that the insurer’s failure to timely respond not only impacted the fairness and integrity of the claim review process but also significantly affected the claimant’s ability to receive a timely resolution to her claim. By advocating for a de novo review, the claimant sought a more objective and comprehensive reevaluation of her entitlement to disability benefits, free from the biases or prior determinations made by the insurer. Ultimately, the court acknowledged the merit in this argument, applying the de novo standard to secure a fair judgment on the facts presented.
The Court Granted Judgment In Favor of the Claimant
Ultimately, the court sided with the claimant, granting her motion for summary judgment. The judge’s decision underscored a critical look at the insurer’s practice of selectively acknowledging medical evidence that supports claim denial while disregarding substantial evidence of disability. The court’s ruling not only highlighted the need for insurance companies to engage in fair and thorough reviews of disability claims but also reaffirmed the rights of individuals to receive the benefits they rightfully deserve under their disability plans.
This case serves as a potent reminder of the challenges claimants face and the importance of presenting a comprehensive, well-documented medical record when contesting a denied disability claim. It also illustrates the pivotal role of the judiciary in holding insurance companies accountable and ensuring that the rights of disabled individuals are protected.
The Claimant Will Be Entitled to $750,000 in Disability Benefits
Claim will be restored effective 6/1/2022. Max Benefit Duration is to 2/28/2043.
That’s 20 years and 10 months of payments at a gross benefit of $2,991.67/month.
So the gross total value of the claim is $747,917.50.