Massachusettts Personal Injury Attorney, the attorney, reviews and analyzes a recent U.S. First Circuit Court of Appeals decision. This is the second part of a two part blogpost, involving the denial of an employee long term disability claim, where the insurer both reviewed and paid claims, allegedly giving rise to a conflict of interest. The First Part reviewed facts leading up the to the employee’s application for long term disability insurance, which the insurer rejected, and resulted in an action in Federal District Court.
In June of 2002, the plaintiff employee in this case filed for long-term benefits. She would qualify as disabled under the long-term plan if, for two consecutive years, she was unable to perform the material and substantial duties of her occupation, and subsequently was unable to perform “the material and substantial duties of any occupation”. The same Liberty nurse who had denied her earlier claim, also reviewed this file, which contained medical support for a finding that the plaintiff’s symptoms had become worse. She had also completed an activities questionnaire in which she claimed to have severe restrictions on her ability to sit, stand, walk, drive, and concentrate.
In her second review, the Liberty Mutual nurse discounted the IME report, suggested that the plaintiff’s condition was not as grave as the completed questionnaire implied, concluded that the plaintiff did not qualify for benefits and Liberty denied the claim. The plaintiff requested further review. Liberty responded by hiring a private investigator to observe the plaintiff’s activities. The investigator produced reports and photographs showing that the plaintiff was active.
With this information, Liberty then utilized a referral service furnishing physicians to evaluate the functional abilities of claimants. One of its physicians concluded that the plaintiff was capable of working full-time in her primarily sedentary position. On December 10, 2002, Liberty reaffirmed its earlier denial of benefits.
Fourteen months later, an administrative law judge ruled the plaintiff was entitled to social security disability benefits retroactive to her last day of actual work. The judge premised this decision on a subsidiary finding that the plaintiff was disabled within the meaning of the Social Security Act. Although the definition of disability under the Act differed from the definition of disability under the Liberty’s plan, the plaintiff forwarded the SSDI ruling to Liberty, along with a further report from her rheumatologist, seeking reconsideration of the denial.
Liberty refused to reverse its decision, which resulted in the district court action. The U.S. District Court granted summary judgement to Liberty, deciding that Liberty had not abused its discretion in denying the claim. On initial appeal, the Appeals Court affirmed, but then the United States Supreme Court made a ruling, which changed the substantive law in the area and resulted in a successful request for rehearing of this case.
In rehearing the case, the Court analyzed the Supreme Court’s decision in Metropolitan Life Insurance Co. v. Glenn , 128 S. Ct. 2343 (2008) . There, the Supreme Court had reviewed a denial of benefits by an administrator that passed judgment upon and paid claims under an ERISA-regulated plan. It concluded that courts should recognize that a conflict exists whenever a plan administrator, whether an employer or an insurer, is in the position of both adjudicating claims and paying awarded benefits.