Disability Insurance Blog

Court Finds for ERISA Disability Claimant, Reinstates Benefits

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Tuesday, March 31st, 2015

A Federal Judge has determined that an ERISA disability claimant, a senior human resources representative, suffering from both physical conditions and mental health problems, was entitled to continued long term disability insurance benefits, finding that the claim administrator failed to properly consider the claim, which presented with co-morbid health issues.

The Court determined that the claim administrator improperly “bifurcated” its consideration of the claim issues, and thus failed to consider the combined impact of the physical issues and the mental health problems which were collectively causing impairment. The claimant, whose long term disability insurance claim was denied, suffered from orthopedic problems, fibromyalgia, and spondylosis. The doctor considering the claim on behalf of the administrator determined that “fibromyalgia is a treatable condition” and thus, the claimant was not impaired as a result. The doctor considering the mental health issues involved in the claim determined that due to the claimant’s ability to perform various activities of daily life and to care for her son supported functionality to work.

The Court took the administrator’s determination to task for refusing to consider the impact of pain upon one’s functionality, noting that “findings of chronic pain may not automatically be dismissed by a benefits administrator for lack of confirmable symptoms.” The Court was also troubled by the failure to account for the actual demands of the claimant’s work, when considering her claim.

Because the administrator failed to consider the claimant’s mental and physical condition together and whether they caused her functional limitations, the decision to deny benefits was deemed arbitrary and capricious. The Court thus granted the retroactive payment of benefits to the claimant.

Carrucini v. Triple-S Vida

Remember, there is nothing negative about talking with long term disability insurance lawyers to ensure your claim is processed correctly and fairly.