Nurse Denied Long-Term Disability Benefits By Life Insurance Company

Understanding Long Term Disability Insurance: Lisa Breen's Battle with Reliance Standard

Lisa Breen, a registered nurse at Abington Health, found herself in a legal battle with Reliance Standard Life Insurance Company after being denied long term disability benefits. Breen was forced to stop working in July 2018 due to medical conditions, including focal epilepsy, which significantly impacted her ability to perform her job. In January 2019, she initially received approval for the benefits but faced ongoing challenges from Reliance Standard, who periodically requested updated medical records to assess her continued eligibility.

In October 2019 when Reliance Standard decided to discontinue Breen's benefits, claiming that her symptoms did not prevent her from working. Naturally, Breen appealed this decision and provided additional medical records to support her case. After careful consideration, in January 2020, Reliance Standard reversed the denial of benefits, but only for the "Regular Occupation" period. To qualify for benefits beyond this period, Breen had to demonstrate her incapacity to perform the material duties of any occupation.

Basis for Claim Denial: Medical Opinions and Vocational Review

Unfortunately, the defendant once again denied Breen's claim for benefits beyond the "Regular Occupation" period, citing a lack of sufficient medical evidence regarding her long term disability. This decision came despite Breen's neurologist, Dr. Skidmore, noting her cognitive dysfunction and recommending neuropsychological testing. In an attempt to assess Breen's employability, Reliance Standard's vocational specialist, Mr. Bolks, identified six potential sedentary occupations that Breen could potentially pursue, leading the company to argue that she no longer met the definition of disability under the "Any Occupation" standard as per her life insurance policies.

As her battle continued, Breen had a telephone session with Dr. Skidmore in November 2020, during which she disclosed that she was still experiencing seizures and cognitive side effects. Additionally, Breen sought an evaluation from Kelly Pearson-Caravetta, CRNP, in July 2021, who noted that Breen continued to experience seizures twice a month.

In her appeal, Breen included eight exhibits, consisting of medical opinions from Dr. Skidmore and a vocational review by Wallace Stanfill. Dr. Skidmore heavily emphasized Breen's cognitive dysfunction attributed to seizures and medication, which resulted in frequent absences from work which would make it hard for her to maintain steady income due to her disability.

Taking Legal Action: Breen's Response

Due to the denial of her long-term disability benefits, Breen decided to take legal action against Reliance Standard Life Insurance Company. While the initial denial stood, the defendant partially reversed the decision after considering Breen's compelling case. Breen's vocational expert, Wallace Stanfill, raised concerns about the defendant's flawed residual employability analysis report, further strengthening her argument for disability insurance. 

Both Breen and Reliance Standard filed cross-motions for summary judgment, leading the court to thoroughly review the details of the case. To gain a better understanding of Breen's medical condition, the defendant enlisted the services of James W. Pearce, M.D., for a medical review. However, Dr. Skidmore did not respond to Dr. Pearce's attempts to communicate. Eventually, Dr. Pearce concluded that Breen was capable of full-time work, while Dr. Skidmore disagreed, highlighting her focal epilepsy and cognitive symptoms.

The Burden of Proof: Demonstrating Arbitrary and Capricious Conduct

The court faced the responsibility of evaluating whether to grant summary judgment based on the presence of a genuine issue of material fact. The administrator's decision, subject to review, relied on either a de novo or arbitrary and capricious standard, depending on the terms of the plan. The court made it clear that the burden fell on Breen to demonstrate any arbitrary and capricious conduct by the claims administrator, as established by ERISA regulations.

“Arbitrary and capricious” conduct refers to a standard of judicial review that courts apply to determine whether a decision made by an employer-sponsored benefit plan administrator is valid or not. The term “arbitrary and capricious” is used to describe a decision that is made without a rational basis or in bad faith.

Breen argued that Reliance Standard had violated ERISA regulations by failing to provide a sufficient explanation for the disagreement with the healthcare and vocational professionals involved in her case assessment. However, the court deemed the defendant's explanation as not constituting a severe procedural violation and opted for the arbitrary and capricious standard as the appropriate level of review.

Furthermore, Breen contended that Reliance Standard's decision to prioritize a flawed reviewing opinion over the opinion of her treating provider constituted an arbitrary and capricious action. In response, the defendant argued that its determination, which concluded that Breen had not met the burden of proving disability, was reasonable and supported by medical evidence.

Court's Rationale for Supporting the Defendant's Decision

Ultimately, the court found sufficient evidence in support of a reasonable person agreeing with the defendant's decision. The court emphasized that Breen's treating physicians' opinions did not render the defendant's decision unreasonable. Furthermore, the court highlighted that the defendant was not obligated to accord greater weight to the opinions of Breen's treating physicians than to those of independent medical examiners.

In its evaluation, the court scrutinized the results of Breen's EEG test and concluded that it did not definitively prove the existence of a disabling condition. The case also delved into Breen's claim for long-term disability benefits, initially denied by the defendant but later partially reversed. Throughout, various medical records and reports related to Breen's condition were referenced and analyzed.

The court noted inconsistencies in Breen's self-reported complaints, primarily related to her failure to follow her doctor's instructions regarding reporting seizures. The case also highlighted the recommendation for neuropsychological testing, which had not been conducted at that point. Furthermore, the court evaluated treatment records from a sleep specialist and concluded that they did not provide sufficient substantiation for a finding of total disability.

The court acknowledged and deemed reasonable the defendant's decision not to conduct an independent medical examination. Similarly, the court considered it rational for the defendant to interpret Breen's episode log and sworn declaration as inadequate proof of total disability.

Thinking Beyond the Denial: Navigating Legal and Alternative Options

Having your long term disability claim denied can be a difficult and overwhelming experience. However, it is important to remember that it is not the end of the road, and that there are steps you can take to challenge the denial.

To strengthen your case after a long term disability claim denial, gather all relevant medical records and disability documentation. Consider hiring an experienced disability lawyer who can guide you through the legal procedures, provide expert advocacy, and negotiate on your behalf. Their expertise and established relationships with insurance companies can significantly improve your chances of a successful appeal.

Additionally, don't hesitate to explore alternative options such as social security disability benefits or short term disability insurance if applicable to your situation. Understanding the nuances of these programs can provide a much-needed safety net during this challenging time. Social security disability benefits offer financial assistance to individuals unable to work due to a long-term disability, while short term disability insurance provides temporary income replacement. Although eligibility may vary, consulting with a disability lawyer who can guide you through the application process will increase your chances of success. 

Finally, remember that you are not alone. Resources and support are available to navigate the complexities of a denied long term disability claim and find the financial assistance you deserve. Reach out to support groups, disability organizations, and online communities to connect with others who have faced similar challenges. Their insights and experiences can provide valuable guidance and moral support throughout your journey.