This month’s Friday Five discusses cases that explore some fundamental principles of disability benefit litigation. While players and fans return to the favorite fall pastime of football, albeit in the “new normal” under COVID-19 limitations, a constant focus in that sport is always on basic blocking and tackling. So too, claims administrators must focus on fundamental concepts for navigating disability claims, such as the appropriate standard of review and essential elements of an administrative record.

1. Is a claimant required to clearly articulate a claim against a claim administrator in order to be permitted to proceed on an ERISA claim? Yes, but the standard is very deferential in favor of the claimant. Lewellyan was an occupational therapist who stopped working due to Ehlers-Danlos syndrome. She applied for short and long term disability benefits, and commenced a civil action after her claims were denied. The claims administrator filed a motion for a more definite statement of the plaintiff’s claims, which the court denied, although the court recommended that the plaintiff file an amended complaint to address numerous errors. The court articulated that the standard a claimant must meet is to provide “a short and plain statement of the claim showing that the pleader is entitled to relief.” F. R. Civ. P. 8(a)(2). The court noted that motions for a more definite statement are disfavored. The court ruled that the claimant satisfied the standard by alleging that she was enrolled in her employer’s disability insurance program, that she had premiums deducted from her pay, and that her claim for benefits was denied. The court did note significant issues with the complaint, for example it contained numerous typographical errors, named people unrelated to the litigation (which the court attributed to the claimant’s counsel inartfully using a prior pleading but forgetting to change the names of all parties) and did not cite to any plan provisions that would entitle the claimant to relief. Even so, the court determined that the claimant could move forward without providing a more definite statement. Lewellyan v. Red River Rehab LLC, 2020 WL 5505609 (W.D. La. Sept. 10, 2020).
2. Must a claims administrator accept opinions of a claimant’s treating physicians even if an independent medical review presents a conflicting view? No. The claimant was a new car salesman who underwent open heart surgery. The claimant received long term disability benefits, but his benefits were terminated after it was determined that he no longer met the definition of “total disability.” The claims administrator required the claimant to undergo an independent medical examination, which determined that the claimant was in good health and that his complaints of pain could be managed and did not render him disabled. After the claimant filed a civil action, the claims administrator moved for summary judgment, arguing that the administrative record supported its determination that the claimant wasn’t eligible for benefits. The claimant argued that the claims administrator was “de novo wrong” to resolve a conflict between his treating physicians and the independent medical expert in favor of rejecting benefits. The court, in adopting the report and recommendation of a magistrate judge, ruled that the opinion of the independent medical expert was credible, and the claims administrator was not wrong to rely on it. The court reasoned that the claims administrator was not required to give special weight to the claimant’s treating physicians, and was not required to satisfy a heightened burden of explaining how it resolved the conflicting opinions. Campbell v. Reliance Std. Life Ins. Co., 2020 WL 5491388 (S.D. Fla. Aug. 24, 2020).
3. Can a claims administrator forfeit the deferential abuse of discretion review standard if the record establishes that it created a conflict of interest or procedural irregularity? Yes, if it causes a breach of a fiduciary duty to a claimant. The plaintiff was a nurse but resigned due to issues caused by Charcot Marie Tooth syndrome. After the plaintiff filed a civil action seeking long term disability benefits, the district court granted summary judgment in her case after ruling that the insurer’s benefits determination was subject to de novo review because of a conflict of interest and procedural irregularities involving the insurer. The insurer appealed, arguing that it was entitled to the more deferential abuse of discretion standard of review. The Court of Appeals reversed, ruling that the district court erred by determining that a conflict of interest or procedural irregularity is a trigger for de novo review, rather than just being a single factor in determining if de novo review should apply. After reviewing the conflict of interest and procedural issues, the Court of Appeals concluded that they did not justify using the de novo standard of review. The Court of Appeals rejected the insurer’s argument that it should determine that it was entitled to summary judgment under the abuse of discretion review, and instead remanded the matter to the district court to decide the case under the appropriate standard of review. McIntyre v. Reliance Std. Life Ins. Co., 2020 WL 4951028 (8th Cir. Aug. 25, 2020).
4. Must a claims administrator develop a sufficient factual record to render a reasonable decision on a claim? Yes. Wilstead was a nurse anesthetist who was injured in a motorcycle accident and following surgery developed an addiction to opioids. After paying disability benefits for a period of time, the insurer terminated payments based on independent medical reviews concluding that he did not suffer from long term functional impairment. Wilstead filed a civil action seeking long term disability benefits, arguing that the insurer lacked a sufficient evidentiary basis to terminate his benefits. Specifically, Wilstead argued that the insurer did not adequately review the unique interplay between his occupation as a nurse anesthetist and his medical issue of opioid addiction. The court reviewed the independent medical reviews obtained by the insurer, and determined that the insurer had a reasonable basis to conclude that Wilstead no longer met the definition of disabled. The court granted summary judgment in favor of the insurer. Wilstead v. United Heritage Life Ins. Co., 2020 WL 5441911 (D. Id. Sept. 9, 2020).
5. Can an insurer’s expert opinions on limited medical issues overcome a plaintiff’s broader evidence of overall disability? No. Entz, the plaintiff, was a school teacher with multiple medical issues including heart disease, deep vein thrombosis and Lyme disease. She stopped working due to symptoms such as fatigue and headache. The insurer denied Entz’s claim for disability benefits based on a conclusion that her Lyme disease did not prevent her from performing the essential functions of her job. The district court conducted a bench trial, which entailed reviewing the administrative record to determine if the insurer correctly denied benefits. The insurer argued that Entz’s doctor was a “quack” whose diagnosis of Lyme disease was medically questionable. The court labelled the insurer’s argument a “red herring” that improperly focused on a single issue impacting the plaintiff’s ability to perform her job. The court determined that it should give greater weight to the plaintiff’s treating physicians who treated her “holistically”, rather than the insurer’s experts whose opinions focused on narrow tests and issues. After determining that the plaintiff established that she was disabled, the court determined the value of her claim during her “own occ” 24-month period, ruling that the plaintiff was entitled to $51,511.73.  Entz v. Standard Ins. Co., 2020 WL 5496072 (C.D. Cal. Sept. 11, 2020).