In James Wilson v. Reliance Standard Life Insurance Company, a Michigan District Court ruled in favor of Reliance and found its termination of long term disability benefits to plaintiff Wilson was not arbitrary and capricious.
Plaintiff, an Air Force veteran, was employed by RCF Information System, a defense contractor, as a Programmer/Systems Analyst, a sedentary position. After a little more than three years of employment, he was diagnosed in November 2014 with lymphoma of his spine, a malignant cancer. His claim for short term disability was approved and, as he continued to receive treatment for the lymphoma, his claim for long term disability was also approved.
After review of Plaintiff’s condition as reported by his treating physicians, in December 2016, Reliance terminated his long term disability benefits and defendant appealed. During the appeals process, Plaintiff underwent an IME, which inspired Reliance to uphold its termination of benefits. After exhausting his administrative remedies, Plaintiff filed this ERISA lawsuit.
The Court reviewed Plaintiff’s medical records of his own treating physicians and the report from an independent medical exam (IME) and upheld the termination of benefits by concluding, “There is no question that Plaintiff suffers from a number of health issues. However, ‘the presence of a medically-determinable condition does not necessary translate into a finding of disability.’”
Review of Medical Records of Plaintiff’s Treating Physicians
The Court conducted a comprehensive review of the medical records of Plaintiff’s treating physicians, which actually supported the termination of benefits decision. His lymphoma had been cured, his HIV was under control with medication. Plaintiff was physically active with only a few limitations.
Plaintiff reported he was “well overall” and engaging in many activities, including going to the gym three times a week and engaging in community service.
Review of IME and Vocational Rehabilitation Specialist Reports
• The IME was conducted by a board-certified Occupational Medicine specialist who concluded that despite Plaintiff’s complaints of some pain, those complaints were inconsistent with his medical records and level of activity described there. The doctor opined that Plaintiff was “capable of working fulltime.”
• A Vocational Rehabilitation specialist concluded that since a Programmer/Analyst was a sedentary occupation, based on the medical reports, “Plaintiff would not be precluded from performing his Regular Occupation.”
Effect of Plaintiff’s Qualification for Social Security Disability (SSD) Benefits
Although it was undisputed that Reliance offered to help Plaintiff with his SSD application and that it benefited Reliance financially, the Court found no evidence that this gave Reliance any incentive to deny his disability claim. Since the plan’s definition of disability differs from the SSD definition, the award of SSD benefits did not automatically require Reliance to approve the continuation of benefits.
In this case, Plaintiff had not presented evidence to support his claim that the termination of his long term disability benefits was in any way related to Reliance’s offer to assist him in filing for SSD benefits.
Final Conclusion of the Court
After its comprehensive review, the Court upheld the termination of long term disability benefits, holding “Because defendant has provided ‘a reasonable explanation for [its] decision denying benefits in light of the plan’s provisions… [ ] the decision is neither arbitrary or capricious.”
This case was not handled by our office, but if you are facing a similar situation, contact one of our disability attorneys at Dell & Schaefer for a free consultation.