A Federal Judge in Connecticut has scheduled a trial with live witnesses in an ERISA case, to be decided under the arbitrary and capricious standard of review. Our firm has been able to secure this result, with the Court denying both parties’ motions for judgment, and determining that the Court needed to take testimony in order to more fully develop the record for consideration.
The Court intends to take testimony from the Plaintiff, her treating doctor, and the medical personnel hired by Sun Life to review the claim on its behalf. In doing so, the Court intends to explore the credibility of the witnesses, and the validity of their opinions.
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These issues will impact upon the Court’s consideration of whether Sun Life’s claim determination was an abuse of discretion or arbitrary and capricious, as well as whether Sun Life’s role as a conflicted decision maker was influenced by this financial conflict of interest.
Barber v. Sun Life & Health Ins. Co., 894 F. Supp. 2d 174
Our client’s long term disability insurance benefits were terminated by the third party administrator (TPA), the outside company that administers the disability insurance on behalf of the employer. Many large companies are self-insured as a means of controlling their insurance costs and frequently outsource the administrative side so that the company’s core business is not tied up with this task.
The TPA’s goal is the same as an insurance company – they seek to reduce the cost of the plan and limit benefits.
Our client, a fifty year-old male, suffers from Multiple Sclerosis (MS), a degenerative musculo-skeletal disease that is exacerbated by anxiety and stress. Learning that his benefits had been terminated had a negative impact on his already bad condition.
To make matters more frustrating, he had already complied with a request from Sedgwick, the third-party administrator, to undergo an Independent Medical Examination (IME), even though he had already undergone a prior IME that clearly showed he was unable to work in his prior occupation as a Design Support Engineer. Sedgwick was going to keep sending him for IMEs until they found a doctor who would give them a diagnosis which would support a reason to stop paying his benefits.
Individuals who suffer from debilitating disabilities are not able to easily travel to doctor’s appointments, and the anxiety generated from attending a doctor’s appointment can lead to worsening symptoms. This was the case for our client, who was being cooperative with the TPA’s requests, but a series of IMEs was not in his best interest, neither for his medical condition nor for reinstating his benefits.
Frankel & Newfield used our experience and our negotiating skills, starting with engaging Sedgwick to interact with us. First, we were able to get Sedgwick to allow a third IME to be conducted, and to agree to pay the client’s monthly long term disability insurance benefits while the third IME process was pending.
The next step was to negotiate with Sedgwick on the selection of a physician to conduct the third IME. We identified a doctor who was truly neutral and not in the third party administrator’s pocket or on their payroll. By fighting to get a medical examination that was truly independent and unbiased, we were able to present our client’s medical condition in an honest manner that reflected truthfully his medical condition. The third IME very clearly demonstrated that our client was physically not capable of performing the specific tasks and duties of his occupation as a Design Support Engineer.
Our client is now getting paid, without any reservations of rights.
This is an example of disability insurance matters that can be resolved through negotiations, knowledge of the claims process, and a skill set that works in and out of the courtroom. If you or a loved one suffers from a degenerative disease and going to work every day has become more and more difficult, it is recommended that you speak with an experienced long term disability insurance lawyer to learn what your options are. Going out on claim is not a simple matter, and strong legal representation is necessary to protect yourself and your family.Ready To Talk?
Courts took disability insurance advocacy into a new world when the Met Life v. Glenn case made it clear that the potential for abuse under ERISA rules pose problems for claimants that may be unfair. In our own case, Hogan-Cross v. Met Life, the United States District Court for the Southern District of New York agreed that when an insurance company trying to stop a claim is also the entity paying for a doctor to give an allegedly impartial review of a case, there is a significant conflict of interest.
In our case, the Court permitted presentation of documents that regarded the nature and extent of the relationship between the insurer and its hired doctors, who are alleged to be "independent" consultants. The Court relied upon other decisions granting discovery which Frankel & Newfield secured, including Trussel v. CIGNA.Ready To Talk?
Justin Frankel is a founding partner of the disability insurance law firm Frankel & Newfield and is a highly skilled litigator and advocate. He has published numerous articles on the challenges facing clients with private or individual disability insurance policies and those who own group or ERISA disability insurance policies.
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