Medical Records Are the Key Ingredient to a Durable Administrative Record in ERISA Disability Insurance Cases

Most ERISA lawsuits proceed in Federal court. ERISA plaintiffs are not entitled to jury trials.  Instead, ERISA lawsuits are resolved in bench trials based upon the administrative record.  The facts contained in the administrative records are gathered during the claim review process and the administrative appeal before the lawsuit is filed.  An extremely important component of any administrative record are the plaintiff’s medical records.

Insurance companies that fund employer provided benefit plans have financial incentives to deny meritorious claims.  In many cases, they will retain experts to closely examine your medical records to find any basis to avoid paying you.  One argument that insurance companies like to make is that your doctor’s treatment records do not document findings that support your claim that your condition is severe enough to prevent you from working.  This was exactly what happened in the recent decision, Paul Luu v. First Unum Life Ins. Co. of Am., 2019 WL 6622848 (C.D. Cal. Nov. 14, 2019) (“Luu”).  Luu demonstrates how accurate and thorough medical records can provide the court with the necessary evidence to overturn a denial of long-term disability benefits.

On February 12, 2015, Paul Luu (“Luu”) received a negative work performance review and notice that he may be terminated.  Immediately afterwards, Luu advised his supervisor that he had been having shoulder, back and neck pain for over two years and stated that the events of February 12, 2015 forced him to seek medical treatment.  Luu called in sick on February 13, 2015 and sought medical treatment on February 16, 2015.  For the next sixteen months, Luu was treated by an orthopedic surgeon, a psychologist, a geriatrics and pain management specialist, a neurological specialist, underwent five MRIs and a nerve conduction studies.  Luu filed a short-term disability claim and his benefits were approved, but his long-term disability claim was denied based on the opinions of six on-site First Unum Life Insurance Company (“Unum”) physicians that performed medical record reviews and concluded Luu was able to work at a sedentary job.

Luu ultimately filed a lawsuit against Unum.  The parties stipulated that the court apply the de novo standard of review to determine whether Unum’s long-term disability claim denial was correct.  Under the de novo standard, the court independently considers evidence, facts and determines how the policy applies pursuant to evidence in the administrative record as it existed when the denial was made.

Unum first argued that Luu stopped working due to impending termination and not medical impairment.  However, the court disagreed due to the detailed history of physical and mental symptoms contained in the administrative record.  The administrative record confirmed that Luu had neck pain for three years leading up to his last day, lower back pain for four to five years worsening in the last three months, shoulder pain for eight months, and wrist pain for approximately two months prior to his last day.  In addition, the medical records stated his mental disorders were “directly related to his exposure to stress and harassment … while at work.”  The court concluded that Luus’ recollection to physicians describing a history of medical conditions and its mention in the administrative record proved that Luu did have symptoms, which were the basis of his disability, prior to the threat of pending termination.

The Unum physicians had also largely based their denial on the fact that EMG testing was not done.  However, EMG testing had been performed in March 2015, but this testing had not been included in the administrative record.  Although the administrative record is usually deemed closed after the appeal process, the court admitted the EMG testing at the trial for the following reasons: 1) The EMG testing is timely and relevant as to Luu’s condition during the period of disability; 2) Although this evidence was available during the appeal process, there was no indication that Luu understood the importance of this specific testing based on the initial denial letter; and 3) The Unum physicians largely based its denial on the noted that EMG testing was not performed, when in fact it had.

Finally, the court had to rule on the several conflicting opinions of Luu’s five treating physicians and Unum’s six on-site, file-review physicians.  In conducting its de novo review, the court is required to “evaluate the persuasiveness of conflicting testimony and decide which is more likely true.  While there is no presumption in favor of a claimant’s treating physician, the court may ‘take cognizance of the fact … that a given treating physician has a greater opportunity to know and observe the patient than a physician retained by the plan administrator.’” *14 When two physicians had conflicting opinions, the court looked at the physician’s specialty, among other things, to determine whose opinion should be given greater weight, or whether a physician’s opinions were based on objective and subjective medical evidence, rather than conclusory or unsupported findings.  The court found the Luu’s treating physician’s reports were very detailed and supported by medical evidence, while Unum’s conclusions were largely based on conclusory statements and partial information, such as there was no EMG testing.  Therefore, the court found the evaluations by Luu’s treating physicians more convincing than those of the Unum physicians.

After reviewing the evidence contained in the administrative record, as detailed above, the court found Luu had proven he was both physically and mentally “functionally disabled” during the relevant time period. Accordingly, Unum incorrectly denied Luu his long-term disability benefits and Unum’s denial was overturned.

Luu demonstrates the importance of the administrative record in an ERISA claim.  If you have a disability claim, it is imperative that you discuss with your doctor the significance of thorough medical records, including descriptions of all your symptoms, any difficulties you have performing your daily life, and all treatments and medications.  Without this level of detail in the administrative record, an insurance company can, and most likely will, argue that your treatment records do not support your claim of disability.  The consequence of not understanding the importance of your medical records early in your claim, could cost you your disability benefits.

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