No abuse of discretion in long-term disability (LTD) claim where the plaintiff was prescribed a particular course of treatment and failed to follow the plan
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Disclaimer: This was not a case handled by disability attorney Nick A. Ortiz. The court case is summarized here to give readers a better understanding of how Federal Courts decide long term disability ERISA claims.
Case Name: Stephanie Shaw v. Life Insurance Company of North America
Court: United States District Court for the Central District of California.
Type of Claim: Long Term Disability.
Insurance Company: :Life Insurance Company of North America (hereinafter "LINA").
Claimant's Employer: Colony Advisors, LLC.
Claimant's Occupation / Job Position: Legal Assistant.
Disabilities: severe anxiety, depression, sleeping problems, tachycardia, and headaches.
Definition of Disability: Under the Plan, an employee is considered disabled and entitled to payments if, "solely because of Injury or Sickness, he or she is (1) unable to perform the material duties of his or her Regular Occupation; and (2) unable to earn 80% or more of his or her indexed earnings from working in his or her Regular Occupation."4 An employee's "Regular Occupation" is "[t]he occupation the Employee routinely performs at the time the Disability begins. In evaluating the Disability, the Insurance Company will consider the duties of the occupation as it is normally performed in the general labor market in the national economy. It is not work tasks that are performed for a specific employer or at a specific location."
The Plan also provides that, "[a]fter Disability benefits have been payable for 24 months, the Employee is considered Disabled if, solely due to Injury or Sickness, he or she is: (1) unable to perform the material duties of any occupation for which he or she is, or may reasonably become, qualified based on education, training or experience; and (2) unable to earn 60% or more of his or her Indexed Earnings."
Benefits Paid? No. Benefits were never approved. The claimant exhausted her administrative appeals with LINA
Issues: (1) Whether the Court should consider evidence that was outside the administrative claim file: "LINA requests the court take judicial notice of (1) the civil Complaint in Stephanie Shaw v. Colony Advisors, LLC, et al., Los Angeles Superior Court Case No. BC500153, filed January 30, 2013; and (2) the Confidential Separation Agreement and General Release, which memorializes the parties' settlement in that case." (2) Whether the claimant provided "satisfactory proof" of disability: the claimant must proffer evidence not only that she has a relevant diagnosis, but also that the illness or injury precludes her from performing the tasks required by her regular occupation. (3) The claimant asks the court to give significant weight to the opinions of her treating physicians, particularly Dr. Levy. (4) Whether the claimant's failure to follow a recommended treatment plan is sufficient to deny a disability claim.
Holdings:
(1) "The court thus declines to expand the administrative record to consider the complaint and settlement agreement in Shaw's suit against her employer at the present time."
(2) Under the policy, Shaw was required to provide "satisfactory proof" that solely because of injury or sickness, she was unable to perform the material duties of her regular occupation. She was also required to provide "any information or documents needed to determine whether benefits [were] payable." The Court held, "In sum, the medical information in the administrative record is not sufficient to satisfy Shaw's burden of showing by a preponderance of the evidence that she was unable to perform the material duties of her regular occupation. The medical evidence is conclusory and inadequate to determine Shaw's occupational abilities." The court considered other non-medical evidence as well: "The administrative record contains several other pieces of evidence that the parties cite to prove or disprove Shaw's entitlement to disability benefits; none, however, is ultimately persuasive. … In addition to medical records, Shaw included with her appeal a narrative statement concerning her symptoms as well as letters from her family and friends. These letters paint a more dramatic picture of Shaw's condition than the medical records, and describe the impact Shaw's mental illness has had on her personality and lifestyle. While the court does not doubt that Shaw struggles with symptoms of her condition, ultimately it cannot rely on these narratives to find that Shaw is entitled to disability benefits."
(3) "The records supply little, if any, evidence – beyond Dr. Levy's word – that Shaw was unable to perform the duties of her regular occupation. Nor do his reports include any descriptive or objective information that would support such a finding. Given the potential for bias, Dr. Levy's assessment alone is not sufficient to support a finding of disability."
(4) "Dr. Eroshevich's records also show that Shaw refused psychiatric medication, requested alternative and holistic treatments, and was not motivated to comply fully with Dr. Eroshevich's treatment plan. … Courts discredit a plaintiff's subjective belief that she is disabled if she refuses treatment or is not diligent in following a treatment plan that could alleviate her symptoms. … Shaw's failure to comply with recommended treatment plans and her refusal to seek certain types of treatment do not preclude her from demonstrating that she was disabled and entitled to benefits. Rather, they are factors to weigh in assessing credibility, and carry more or less weight depending on her diagnosis and her reasons for failing to follow recommended treatments. … Here, the record contains no evidence as to why Shaw refused psychotropic medications. Nor is there any particular explanation as to why she declined to follow the treatment plan Dr. Eroshevich prescribed… ."
Summary: The Court granted Defendant LINA's Motion for Summary Judgment: "In sum, the medical reports in the administrative record are not sufficient to show by a preponderance of the evidence that Shaw was unable to perform the material duties of her regular occupation. The only reports that support her claim are conclusory, and provide insufficient information concerning Shaw's functional capacity."
Here is a PDF version of Shaw v. LINA available for download: