Court Reinstates Disability Benefits Because Insurer’s Vocational Expert Ignored Treating Physicians’ Opinions

When an insured becomes disabled and incapable of performing the duties of his or her occupation, long-term disability benefits can provide a much-needed form of substitute income. Given the potential importance of these disability insurance benefits, playing an active role in the claims handling process is integral to the success or failure of an insured’s claim. In marshaling medical evidence in support of a long-term disability, insureds often rely on the opinions of their treating physicians and rightfully so, as the support of a treating physician can make or break a claim. However, the support of treating physicians does not equate to automatic approval of benefits. Typically, an insurer will hire its own medical or vocational expert to evaluate a claim. Often, these experts reach an opposite conclusion, finding that the insured can perform the material duties of his or her own occupation and is not disabled within the meaning of the plan.

Recently, the District Court for the Eastern District of Michigan, in Julie Sun v. United of Omaha Life Ins. Co., 2:16-cv-11339-VAR-RSW, 2017 WL 3050477 (E.D. Mich. July 19, 2017), granted plaintiff’s motion for summary judgment, finding the plaintiff was disabled despite the insurer’s reliance on a vocational expert’s opinion in support of its denial. In this plaintiff-friendly opinion, the court openly criticizes the insurer’s “cherry picking” of evidence and failure to give the opinions of plaintiff’s treating physicians due consideration.

In Julie Sun, Ms. Sun filed a lawsuit under the Employee Retirement Income Security Act of 1974 (“ERISA”) to enforce and clarify her rights under a long-term disability plan issued to her employer by United of Omaha Life Insurance Company (“United”). Prior to her disability, Sun worked as a registered nurse caring for quadriplegic patients. Unlike most sedentary positions, her position demanded a significant level of physical exertion. Ms. Sun’s occupation required that she exert at a “medium” level, which included the ability to lift a maximum of fifty pounds and frequently lift or carry up to twenty-five pounds. Her specific position also required that she be able to operate a “hoyer lift” to move patients, which involved pushing, pulling and lifting about thirty pounds. In addition to assisting patients with daily care activities, such as bathing or dressing, she was also responsible for driving her patients to and from various appointments and other personal errands.

In December 2010, Ms. Sun injured her foot. As a result of her injury and other disabling conditions, she could no longer perform the duties of her occupation as a registered nurse. Unfortunately, Ms. Sun’s foot never healed, and she did not return to work.

After paying Ms. Sun’s long-term disability benefits for some time, United terminated her benefits effective April 6, 2013. In terminating her benefits, United relied on two reviews: a medical review conducted by a Medical Consultant and a Transferable Skills Analysis conducted by a vocational expert. Ultimately, United determined that “the medical documentation fails to substantiate a condition or conditions that would render [Ms. Sun] disabled from performing a Gainful Occupation of a sedentary strength demand.”

The court, however, did not find United’s analysis convincing, noting that the vocational report was “not supported by a reasoned explanation based on the evidence.” Particularly troubling were “United’s findings that Sun can sit for 6 hours in an 8-hour workday and that she can lift less than 10 pounds frequently.” The court found that these statements directly contradicted the reports provided by two of Ms. Sun’s treating physicians, which together supported disability from even sedentary or light work on a sustained basis. On appeal, United’s analysis did not improve, merely restating its position that its “review of the file does not find support for restrictions or limitations which would prevent [Ms. Sun] from performing the material duties of a sedentary occupation from April 6, 2013, and ongoing.”

Contrary to United’s findings, the court concluded that the administrative record did support Ms. Sun’s disability. The court criticized United’s conduct, including the way it “cherry-picked” the opinion of its own, non-examining vocational consultant and failed to give the opinions of Ms. Sun’s treating doctors due consideration. In its opposition to Ms. Sun’s motion for summary judgment, United further argued that its denial was based in part on Ms. Sun’s expected medical improvement. The court found this rationale similarly unconvincing. Although United may have based its termination on “aspirational language in medical reports” it did so while ignoring “ample evidence of disability based on examinations and findings.” Accordingly, the court granted summary judgment in favor of Ms. Sun, finding United’s denial arbitrary and capricious and Ms. Sun disabled within the meaning of the plan.

If your claim for retirement, health, life, short-term disability or long-term disability benefits has been denied, you can call (949)387-9595 for a free consultation with the attorneys of the McKennon Law Group PC, several of whom previously represented insurance companies and are exceptionally experienced in handling ERISA and Non-ERISA insurance claims.

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