According to the
Court’s opinion, the plaintiff began working for the employer in 1998 as a
software engineer and his job required him to sit for 8-10 hours/day and about
70 hours/week. By 2005, his physician advised him to stop working because of
significant back pain for which he was taking medication. He received STD and then applied for LTD
under his employer’s plan, which provided that for the first year he would be
considered to be disabled if was unable (for other than an injury covered by
workers compensation) to engage “in his
. . . occupation or employment at the Company,
for which the eligible employee is qualified, based on training, education or
experience.” (emphasis added). After his
initial claim was denied, he submitted medical documentation concerning his
degenerative diseased discs and how the medication disoriented him and impaired
his cognitive abilities. While his
physician believed returning to work would be in his best interests, he could
not sit for prolonged periods. An IME
revealed no neurological basis for the pain, but suspected psychogenic factors.
The Plan Administrator’s nurse manager reviewed the file and
denied the appeal because that the plaintiff should be able to perform a
sedentary occupation. The Plan Administrator explained that his claim was
denied because his back pain did not make him unable “to work throughout your
entire Benefit Waiting Period.” At this
point, the plaintiff retained an attorney and appealed again. Additional medical evidence was submitted, as
well as an explanation that the employer refused to provide certain accommodations
(such as reduced working hours, etc.). A
physician employed by the Plan Administrator reviewed the file and saw no
clinical basis to support his claimed back pain. The Plan Administrator again denied the
appeal and noted, among other things, that no mental status tests had been
administered to document a cognitive impairment. Again, the plaintiff appealed and submitted
detailed psychological records. After
his final appeal was denied in January 2007, the plaintiff filed for bankruptcy
10 months later and in January 2009 sought review under ERISA of his LTD
application in federal court.
On appeal, the Plan argued that the plaintiff should be
precluded from pursuing the appeal because his bankruptcy petition did not list
the claim on his schedule of assets. The plaintiff showed that the mistake had
been inadvertent because he had communicated the claim to his bankruptcy
attorney. The trial court refused to apply
the judicial estoppel doctrine, which precludes a party from taking
contradictory positions in different litigation. Although the Sixth Circuit noted there was
some authority that judicial estoppels should be reviewed on an abuse of
discretion basis, it applied a de novo review. “We have made clear that
“judicial estoppel does not apply where the prior inconsistent position
occurred because of ‘mistake or inadvertence.’”
Moreover, in this case, the plaintiff lacked a motive to conceal the LTD
claim from creditors: “[U]nder Ohio laws, proceeds from a disability insurance
policy are completely exempt from a debtor’s estate (i.e., set aside for the
benefit of the debtor) to the extent that they are necessary for the support of
the debtor and his family.”
The trial and appellate courts applied a de novo standard of
review of the plaintiff’s LTD claim in this case because, as the Plan’s attorneys
conceded at oral argument, the Administrator’s decision was not entitled to
deference. The Court concluded that the
plaintiff had proved that he was unable to work as a software engineer for the
first year of his LTD application based on a review of his job and the medical
evidence.
Both parties agree that Plaintiff’s job as a software
engineer was technically and intellectually demanding and required sitting for
prolonged periods of time.
. . . The medical
evidence in the administrative record indicates that a combination of extreme
pain, and mental illness, and the effects of pain medication made it exceedingly
difficult for Plaintiff to concentrate, handle stress, stay awake during the day,
remember things, relate to co-workers, make decisions, or sit for any extended period
of time.
Three
treating physicians concluded he was unable to work. In addition,
[o]f the two psychiatrists who evaluated Plaintiff in 2006,
one determined that he was seriously mentally ill and incapable of working, and
the other found substantial impairment in Plaintiff’s ability to sustain the
stress and pressure of day-to-day work. Their diagnoses were confirmed shortly
thereafter by Dr. Borders, a psychiatrist at Shepherd Hill behavioral health
facility, when Plaintiff was hospitalized for twelve days for mental illness in
an acute in-patient unit in September 2006.
The Court found that the opinions of the Plan’s medical
experts were insufficient to counter the plaintiff’s medical file. While none of them found an objective basis for
the plaintiff’s back pain, one of them suspected a mental cause. Another physician complained about the lack
of objective evidence and then overlooked such evidence in the file. For example, he complained about the lack of
psychological tests and then overlooked such a test that had diagnosed severe
depression. He also noted that
non-mental health providers had not provided information about his mental
health when, in fact, they had. Finally,
he had ignored the requirements of the plaintiff’s software engineer position.
First, file reviews are questionable as a basis for
identifying whether an individual is disabled by mental illness. See Smith
v. Bayer Corp. Long Term Disability Plan, 275 F. App’x 495, 505–09 (6th
Cir. 2008) (noting that “[c]ourts discount the opinions of psychiatrists who
have never seen the patient for obvious reasons”). Second, reliance on a file review is inappropriate
where a claims administrator disputes the credibility of a claimant’s complaints.
. . . .
Plaintiff submitted medical evidence from numerous doctors
and therapists who directly treated or examined him and concluded that he was
unable to work due to a combination of his physical and mental conditions. He
visited over a dozen medical experts. Those doctors who knew him best
concluded, unequivocally, that he was unable to work at the relevant time. Defendant offers little to contradict this
evidence. Accordingly, Plaintiff is entitled to disability benefits for the
relevant period.
NOTICE:
This summary is designed merely to inform and alert you of recent legal
developments. It does not constitute legal advice and does not apply to any
particular situation because different facts could lead to different results.
Information here can change or be amended without notice. Readers should not
act upon this information without legal advice. If you have any questions about
anything you have read, you should consult with or retain an employment
attorney.
