This case was not handled by our office, but claimants may find it instructive on the topic of treatment for pre-existing conditions during a waiting period for benefits established by an insurer as well as on the topic of being disabled from a claimant’s own occupation.

The case of Oxford v. Anthem Life Insurance Company is complex, raising several issues including termination of short term disability benefits when plaintiff failed to follow through on recommended treatment, denial of long term disability benefits, and Anthem’s termination and denial of all benefits on the grounds that plaintiff received treatment for fibromyalgia, anxiety and depression during the pre-existing condition treatment period. Anthem won in court on all issues with the court concluding that “Anthem’s denial of Ms. Oxford’s short term and long term disability benefits was not arbitrary and capricious.”

Termination of Short Term Disability Benefits

Six months after being employed as an Eligibility Manager with Med-Assist, plaintiff worked her last day and applied for short term disability benefits because of lower back pain, depression and anxiety. She was initially awarded short term disability benefits. A review of her medical records showed she had “a history of fibromyalgia” and recommendations for certain treatment for other conditions such as carpel tunnel syndrome.

She failed to follow-through with the recommended treatment as required by Anthem, so her benefits were terminated. She appealed, claiming she was unable to pay for the recommended treatment. Anthem’s three independent reviewers of medical records found no objective evidence of disability, gave no allowance for her not being able to afford treatment and denied her appeal. The medical review also indicated she had received treatment for her conditions during the pre-existing treatment period.

Denial Long Term Disability Benefits

Plaintiff’s application for long term disability benefits were denied for essentially the same reasons as the denial of her short term benefits. Additionally, a vocational rehabilitation review indicated that she could meet all the requirements, both physical and environmental, of all the duties of her own occupation. A functional capacity evaluation (FCE) found there were no tasks of her own occupation she was unable to perform. Her application was denied and she appealed.

Appeal of Denial of Long Term Disability Benefits

Anthem chose a physician who was board-certified in both internal medicine and rheumatology to review her medical records. He agreed with the diagnosis of fibromyalgia, but could not conclude that she had received treatment for the condition during the pre-existing treatment period and offered alternative reasons for the prescriptions drugs she was taking during that time. As for her ability to do her job, he suggested certain restrictions and limitations that would still allow her to do it.

Her appeal was denied on the grounds that she could perform the duties of her own occupation and was not disabled. She then filed this ERISA lawsuit.

District Court Opinion Upholding Anthem’s Denial of Benefits

After a detailed review of the administrative and medical records, the district court held that Anthem’s decision was “reasonable” at every stage of the administrative process. Plaintiff’s medical records were not “overwhelming in favor of her claim.” The court expressed its “empathy” with her inability to pay for follow-up treatment, but did not let that emotion get in the way of its determination that she did not meet the requirements of the plan.

As to Anthem’s conclusion that she could perform the duties of her own occupation, the court concluded that “there is rational support in the record for this conclusion.” The district court upheld all of Anthem’s decisions and the plaintiff lost her case.