Federal Court Overturns LTD Denial by Sedgwick’s Dr. Mendelssohn
Wednesday, June 20th, 2018
Our disability insurance law firm has come up against Sedgwick, a third party administrator of disability insurance claims, and Dr. Martin Mendelssohn, an orthopedist who is a hired gun for many insurance companies, performing paper only reviews supporting claim denials and terminations, so it is always rewarding to read about a federal judge who agrees with our position: long term disability insurance companies have an obligation to consider the side effects of the medication that claimants use on their ability to perform their jobs.
Lisa Connor was a perioperative nurse at a large medical center, where she participated in the long term disability (LTD) plan. She was involved in a an auto accident and had injuries to her neck, left shoulder and left arm on May 20th, and stopped working on May 22. She required surgery to her left rotator cuff, torn in the accident. She started seeing a spine and pain management physician every month due to chronic pain in her neck, left shoulder and left arm. The pain medicine helped with pain, but impaired her ability to function.
When Connor’s short term disability was exhausted, she was converted to long term disability (LTD.) According to the language of her plan, she was eligible for benefits after two years only if she is disabled from any occupation for which she is “reasonably qualified.” She was approved for LTD in November 2013, and benefits were to have ended November 2015, two years later.
In September 2015, a Sedgwick nurse case manager reviewed her claim to see if she would qualify to receive benefits after the two year mark. On November 12, Connor underwent a Functional Capacity evaluation (FCE), a notoriously challenging test that we advise our claimants not to take, or not to take without a witness present. The FCE indicated that she was able to occasionally lift up to 20 pounds, but could not reach overhead with her left arm. The FCE concluded that she could function in a light physical demand category, and noted that the medications she was taking did in fact cause some cognitive impairment.
A psychological evaluation, medical records and vocational assessments were submitted.
The psychological evaluation doctor stated that she had severe deficits in attention and concentration skills, and had a very hard time staying focused and remaining on task. He added that she continues to be fully and totally disabled from a psychological perspective and could not perform any work on an 8 hour a day, 5 day a week basis.
Her doctor continues to prescribe medications to alleviate her chronic pain, some of which are quite strong; morphine is one of them. This doctor said she would be unable to work as a nurse or in any other job.
The vocational assessment presented a similar evaluation; that she would not be able to work in any nursing capacity.
Sedgwick, a third party administrator, handed her case over to Dr. Martin Mendelssohn, known in the Long Term Disability insurance community as one of the doctors who bounces every case that crosses his desk. Connors was no exception. Facts cannot get in Dr. Mendelssohn’s way.
Dr. Mendelssohn trivialized her complaints, saying that she had “ongoing self reported complaints, and that her history and physical examination indicating functional or neurological deficits is not provided that would substantiate the need for restrictions.”
Connor filed a lawsuit, claiming that she had been improperly denied LTD benefits, seeking reinstatement of said benefits and an award of her unpaid LTD benefits.
Ascension and Sedgwick filed a cross motion for summary judgment, asserting that their denial was reasonable and also filed a counterclaim to recover the amount of money paid in LTD benefits while she was receiving Social Security Disability.
The Eighth Circuit Federal Court concluded that under certain circumstances, the side effects of treatment or medication can be disabling under ERISA. The failure of Sedgwick and Dr. Mendelssohn to consider the side effects of medicine prescribed was unreasonable and an abuse of discretion.
Dr. Mendelssohn cited medical records documenting that she was prescribed drugs pain medicine after the car accident to treat her pain and that her advisors said she was unable to work due to the side effects of the medications, but never addressed her assertion that the side effects caused cognitive impairments, nor did he explain his conclusion that she lacked functional or neurological deficits.
While plan administrators are not required to provide an explanation for their decision when they credit reliable evidence that conflicts with a treating physician’s evaluation, they may not arbitrarily refuse to credit a claimant’s reliable evidence, including the opinion of a treating physician. Black & Decker Disability Plan v. Nord, 538 U.S. 822 (2003).
Sedgwick’s reliance on Dr. Mendelssohn’s conclusion to deny her benefits was an abuse of discretion, since he failed to consider how these medications impacted her ability to work.
Cross motions for summary judgment are denied and case is remanded to plan administrator for reevaluation.
Connor v. Ascension Health & Sedgwick, 2018 U.S. Dist. LEXIS 102064