Disability benefits appeal denied despite primary MD’s report p4

We are picking up our discussion of a case out of the 8th U.S. Court of Appeals regarding an employee’s long-term disability benefits claim.

The claimant had a number of physical ailments. His plan had two benefit periods. During the first 24 months, the claimant had to be unable to perform the duties of his “own occupation”; after that, benefits would only continue if he were unable to perform the duties of “any occupation.” When the transition point came around, his treating physician completed the insurance company questionnaire.

The treating physician reported that the claimant was unable to work. The file then went to an insurance company consulting physician for review, and that doctor, after misreading part of the treating physician’s report, determined that one of the injuries didn’t seem too serious.

Because the plan defines “any occupation” in terms of the claimant’s education, training and experience, the file was next delivered to a vocational case manager for his opinion. In his report, he said the claimant was fit for certain sedentary jobs.

The insurer denied the claim. The benefits would not continue, because the claimant was, according to the insurance company’s consultants and employees, fit for a handful of jobs.

The appeals court will only overturn a benefits decision under an ERISA plan if the administrator has abused its discretion, or if the benefits decision is inconsistent with the disability plan’s goals, conflicts with ERISA, interprets terms differently here from in past cases, and so forth. The decision essentially must be arbitrary or clearly wrong.

In our next post, we will explain the court’s decision.


Alan Olson writes this web-log to provide helpful information regarding long-term disability cases. He practices long-term disability law throughout the United States from his offices in New Berlin, Wisconsin. Attorney Olson may be contacted at [email protected] with questions about the information posted here or for advice on specific disability benefit claims.

Source: Leagle.com, Carrow v. Standard Insurance Co., — F.3d —-, C.A.8 (Mo.)


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