In a recent ruling from the United States District Court District for the Western District of Michigan, a Judge ruled that Liberty Life Assurance Company of Boston was wrong in denying continued Long Term Disability Benefits to Michelle R. Rouleau.

Facts of the Case

Ms. Michelle R. Rouleau previously worked as a registered nurse for Sparrow Hospital in Michigan. She was forced to stop working in June of 2012 due to intractable back pain. Prior to her claim, Ms. Rouleau had a long history of treatment which included times of relief and times of experiencing more pain. After years of treatment including epidural injections and bilateral facet block, a lumbar fusion surgery was finally performed in June of 2012. Following the surgery, Ms. Rouleau had planned to return to work within 10 weeks. After initially feeling relief in the first few weeks after surgery, by August of 2012 Ms. Rouleau’s pain level had increased and long term disability benefits were applied for and approved in September of 2012.

After Long Term Disability (LTD) benefits were approved, Liberty Life encouraged Ms. Rouleau to apply for Social Security Disability Benefits. Under the LTD policy through her employer, Social Security Disability Benefits would be an offset to her LTD benefit from Liberty Life and the policy actually required that she applied for such benefits. In early 2014, Ms. Rouleau was approved for Social Security Disability Benefits and repaid the overpayment owed to Liberty for Social Security benefits she received retroactively.

In April of 2014, Liberty Life then began its review for continued benefits beyond the “own occupation” period of benefits. As is common in most group disability insurance policies, the policy through Mr. Rouleau’s employer contained a typical “change in definition of disability.” As such, what it means to be disabled under the policy will change after a set time period. Most often this change in definition occurs after benefits have been paid for 24 months. Thus, in order for Ms. Rouleau to initially qualify for benefits she had to prove that she was unable to perform the duties of her own occupation. Now, after 24 months of benefits, in order to be approved for continued benefits, she would have to prove that she was unable to perform the duties of any occupation.

Unfortunately for Ms. Rouleau, the results of Liberty Life’s review were not favorable and they denied continued benefits. In support of its decision to deny, Liberty Life relied upon a “paper” review conducted by a doctor who only reviewed Ms. Rouleau’s medical records but never personally examined her. This doctor found that she had no restrictions on sitting for an 8 hour day. Liberty exclusively relied up on this opinion and had a vocational specialist find other occupations that Ms. Rouleau could perform with their reviewing doctor’s given restrictions and limitations. After finding sedentary jobs that it believed Ms. Rouleau could do, Liberty Life denied continued benefits. Although Ms. Rouleau appealed, Liberty upheld its denial and this lawsuit followed.

Ruling of the Court

The Court ultimately ruled that Liberty Life’s decision to deny benefit was wrong. Utilizing a “de novo” standard where the Court simply determined whether the denial of benefits was the “correct decision”, the Court felt that a preponderance of the evidence weighed in favor of a benefits award. The Court cited the significant medical record that contained objective evidence as well as the Social Security Administration’s finding that Ms. Rouleau is totally disabled from employment. The Court made it a point to state that although such an approval from the Social Security Administration does not make her automatically entitled to benefits under the LTD policy, the Court noted that the Social Security Administration’s determined was “far from meaningless.”

The Court also noted that Liberty failed to explain why Liberty afforded greater weight to its reviewing doctor’s report than to the reports of Ms. Rouleau’s own treating physicians. The Court opined that although “the Sixth Circuit has stated unequivocally “that there is “nothing inherently objectionable about a file review by a qualified physician in the context of a benefits determination,” the court has also approved assigning more weight to evidence from a treating physician than a record reviewer who did not conduct an in-person evaluation.” The Court ultimately assigned little weight to Liberty’s doctor’s report and opinion.

The Court found that the “preponderance of the evidence – indeed, the great weight of the evidence- reflects that Ms. Rouleau remained “disabled” as the Policy defines it even after the expiration of the “own occupation” period and is therefore entitled to the long term disability benefits she seeks.”

The ruling of this case should serve as a reminder that ERISA LTD cases are winnable at trial. Just because an insurance company has denied a claim and cited to a doctor’s opinion in support of its denial does not mean that the decision is a correct one. Many of these paper reviews are not worth the paper they were written on and the opinions are not always credible.

If you have an active claim or have been denied benefits by Liberty Life or any disability insurance provider, please do not hesitate to speak with a Lawyer at Dell & Schaefer. Disability lawyers are available at your convenience to have a complimentary phone conference.