This month’s Friday Five explores recent decisions that range from the effect on disability benefits when medical records are not provided after two appeals, to a case that examines how an award of death benefits is determined, to a finding that an insurer’s decision to terminate benefits was not arbitrary and capricious.  

1. Whether Principal Life Insurance Company's denial of Plaintiff’s LTD and LCDD claims was arbitrary and capricious when the decision-making process suffered from the same deficiencies that were previously noted by the Sixth Circuit? Susan Card (Plaintiff) filed her initial complaint against the Principal Life Insurance Company (Defendant), seeking judicial review of Defendant’s denial of her claims for disability benefits. On Appeal, the Sixth Circuit determined that Defendant’s denial was arbitrary and capricious and vacated the District Court’s summary judgment order and remand[ed] the case to the Defendant for further proceedings. Following the remand Defendant approved Plaintiff’s claim for short term disability benefits ("STD") and requested medical information from Plaintiff’s counsel so that it could review her remaining claims for long term disability ("LTD") and life coverage during disability ("LCDD") benefits. Plaintiff filed a motion to reopen her case and did not provide any other information that Defendant had requested from her. At that time Defendant formally denied Plaintiff’s claims for LTD and LCDD benefits. The Sixth Circuit granted Plaintiff’s motion to reopen and deemed Plaintiff to have exhausted her administrative remedies for her claims because Defendant did not issue a determination of her claims within the Department of Labor's 45-day deadline for ERISA claims. The United States District Court for the Eastern District of Kentucky found that Defendant failed to remedy many of the deficiencies that the Sixth Circuit already rendered arbitrary and capricious when reviewing Defendant’s initial denial of Plaintiff’s LTD and LCDD claims on the First Appeal. The Court held that since the Sixth Circuit already deemed these actions arbitrary and capricious, this Court is bound to do the same. During the First Appeal, the Sixth Circuit remanded the case because it "[could not] say on the record that Plaintiff is entitled to short term and/or long-term disability benefits." The Court found that the record before the Court essentially remained the same as the one before the Sixth Circuit because Plaintiff failed to submit additional evidence of her LTD and LCDD claims as requested. Accordingly, the Court remanded the claim (again) to Principal to make a determination on the claim. Card v. Principal Life Ins. Co., No. 5:15-139-KKC, 2023 U.S. Dist. LEXIS 156292 (E.D. Ky. Sep. 5, 2023).
2. Who is eligible for the death benefits of murdered claimant – her fiancé or her son? Dominique Bowers began working for Northrop Grumman (Employer) in March 2021 and signed up for life insurance and accidental death and dismemberment benefits provided by Northop Grumman's Employee Benefit Plan (Plan), which was administered by Metropolitan Life Insurance Company (Insurer). Bowers was murdered in August 2021 and had not name a beneficiary. The Plan provides an order of preference for payment—"spouse or domestic partner" is first in line, followed by children if there is no spouse or domestic partner. Bowers’ fiancé, Nikolaos Zaharopoulos, filed a claim for the death benefits as Bowers’ "domestic partner." Bowers’ aunt filed a competing claim for the death benefits on behalf of Taylor, who was Bowers’ minor son. The plan provided that a Domestic Partner declaration attesting to the relationship between the employee and the employees’ domestic partner must be completed and signed by the Employee. The declaration must establish that each person has either a substantial interest in the other engendered by love and affection; or a lawful and substantial economic interest in the continued life, health or bodily safety of each other, as distinguished from an interest which would arise only by, or would be enhanced in value by, the death, disablement or injury of the other person. The insurance company initially granted death benefits to Zaharopoulos, and Taylor appealed the Insurer’s decision, arguing that Zaharopoulos was not Bowers’ domestic partner. The court found that Bowers was required to sign and submit the domestic partner declaration. Without that declaration, Zaharopoulos was not Bowers’ domestic partner as defined by the Plan. As a result, Taylor was entitled to the death benefits. Zaharopoulos v. Taylor, 2023 U.S. Dist. 157807 (M.D. Ga. Sep. 6, 2023).
3. Whether a disability insurance carrier was wrong when it determined that an insured was no longer disabled and terminated her benefits? Plaintiff worked for Workday, Inc. (Employer) as a software trainer and was eligible to participate in the employer’s long-term disability policy. Plaintiff stopped working on August 27, 2016, because of disabling and painful migraine headaches. Defendant approved Plaintiff’s claim for long-term disability benefits but terminated the benefits after issuing monthly disability benefit payments for more than five (5) years. Plaintiff filed an appeal of Defendant’s termination of benefits. The Judge concluded that Plaintiff’s termination decision was incorrect because it relied upon isolated and sporadic notes regarding temporary improvements without considering other medical notes and evidence confirming that Plaintiff’s migraine headaches, while better temporarily and for a short while, have worsened and prevented her from working with reasonable continuity. The Judge acknowledged that Plaintiff improved temporarily but concluded that Plaintiff’s migraine headaches were still severe enough to prevent her from working on a consistent basis. Under the terms of the policy, Plaintiff had to demonstrate that she cannot work in any job -- a burden greater than the initial standard of not being able to work in her former job. The Judge found that Plaintiff has met her burden of establishing that she was disabled and that the carrier's benefits termination decision, based on the record evidence, was wrong. Dooley v. Unum Life Ins. Co. of Am., No. 22-23808-CIV-SCOLA/GOODMAN, 2023 U.S. Dist. LEXIS 130175 (S.D. Fla. July 27, 2023).
4. Whether Unum acted arbitrarily and capriciously by terminating Plaintiff's LTD and LWOP benefits? Plaintiff brought an action against Unum Life Insurance Company of America’s (Defendant) termination of Plaintiff's long term disability insurance benefits (LTD benefits). Plaintiff worked for Pharmaceutical Product Development, LLC as a clinical research associate and claimed that a disability rendered her unable to perform her sedentary occupation due to severe back and neck pain and attendant radiculopathy. Defendant approved Plaintiff's claim for STD benefits. When Plaintiff reached the end of her STD benefits, she applied for LTD and waiver of premium on the basis of disability benefits (LWOP benefits) and Defendant approved both LTD and LWOP benefits. However, after finding Plaintiff was no longer disabled under the Plans, Defendant terminated her LTD and LWOP benefits. Plaintiff appealed. The Court found that the case hinged upon whether Plaintiff could perform a sedentary job with a sit/stand option. Sedentary work requires mostly sitting during an eight-hour day, may involve standing or walking for brief periods of time, and lifting, carrying, pushing, and pulling up to 10 pounds occasionally. Some sedentary jobs will permit a sit/stand option to continually sitting. The Court found that Defendant did not act arbitrarily and capriciously by terminating Plaintiff's LTD and LWOP benefits and relied upon the following in reaching this conclusion: Plaintiff worked up to walking a mile and a half; her muscle strength returned to normal; she had functional range of motion in her spine; her straight leg raising tests were no longer positive; Spurling's tests were negative; she reduced her pain medication to one pill a day and did not receive any pain injections; and she  was able to do light house work and drive. Olah v. Unum Life Ins. Co. of Am., No. 1:19-cv-00096-KAC-CHS, 2023 U.S. Dist. LEXIS 166890 (E.D. Tenn. Aug. 14, 2023).
5. Whether Plaintiff could perform the work of her current profession or was disabled for the full 24 months for which she contends she is entitled to benefits? Plaintiff worked as a Global Account Manager for the technology company Docusign, Inc. In 2019 Plaintiff began treatment with Dr. Bowen Parsons, MD, for psychological symptoms. Dr. Parsons diagnosed Plaintiff with panic disorder and recurrent major depression episodes. Lincoln National Life Insurance Company (Defendant) originally concluded that Plaintiff was disabled and eligible for long term disability (LTD) benefits, with the expectation that she would return to work or continue to prove ongoing disability. On March 25, 2020, Defendant terminated Plaintiff’s LTD benefits, concluding that Plaintiff could perform the work of her current profession. Plaintiff brought this suit, seeking reinstatement of her LTD benefits for the remainder of the initial 24-month “own occupation” benefit period. Defendant argued that Plaintiff provided insufficient evidence that she was disabled from March 25, 2020 to June 4, 2021, the rest of her "own occupation" period. Defendant pointed to its several independent medical evaluators, who reviewed the medical records and concluded that the records did not support a finding of disability. Plaintiff argued why the Court should discount each of those medical opinions. In 2021, the Social Security Administration found Plaintiff disabled as of March 1, 2020 and granted her application for disability insurance benefits. Plaintiff’s attorney notified Defendant of the Social Security Administration’s decision. The Court granted Plaintiff's Motion for Judgment with respect to the “own occupation” period and denied the motion, as stipulated by Plaintiff, with respect to the “any occupation” period. The Court ordered the Defendant to reinstate Plaintiff’s benefits from March 25, 2020, through June 4, 2021, which is the remainder of the 24-month “own occupation” period of her long-term disability plan. Turkoly v. Lincoln Nat'l Life Ins. Co., No. 3:21-cv-1019-SI, 2023 U.S. Dist. LEXIS 167197 (D. Or. Sep. 20, 2023).