Facts

Plaintiff Adrienne Turner was covered under an ERISA-governed disability insurance plan issued by defendant Union Security Insurance Co. to plaintiff's employer. Plaintiff submitted a claim for long-term disability benefits, but defendant denied her claim, and then upheld that denial decision despite two administrative appeals. Plaintiff sued defendant for recovery of her policy benefits, as well as for interest on the unpaid benefits, attorney fees and costs.

PLAINTIFF'S CONTENTIONS:
Plaintiff contended that she was totally disabled in October 2012 when the cumulative and progressive trauma from job caused her to develop bilateral carpal tunnel syndrome, as well as degenerative disc disease, both degenerative cervical spine and degenerative lumbar spine disc disease, joint pain, muscle pain and stiffness, rheumatoid arthritis, nerve damage and other conditions. Plaintiff's claim for long-term disability benefits was supported by her treating physicians, as well as independent physicians who examined her in connection with her claim for Workers' Compensation benefits.

Plaintiff further contended that defendant's denial decision was neither supported by the evidence in the file, the language of the Plan nor defendant's responsibilities under ERISA. Not only was defendant's decision based on the opinions of paid "paper review" physicians who never examined plaintiff, but it was also based on a 12-minute surveillance video that did not show her acting in any way inconsistent with her claimed restrictions and limitations.

Plaintiff further contended that defendant improperly required her to meet a heightened standard of disability not found in the policy, and failed to engage in a "meaningful dialogue" with her during the claim, as required by ERISA.

DEFENDANT'S CONTENTIONS:
Defendant contended that, notwithstanding the opinions of the treating and independent physicians, plaintiff was capable of performing the material and substantial duties of her occupation, and therefore, was not entitled to long-term disability benefits under her policy. Defendant supported its position by relying on the surveillance video and the opinions of five physicians it hired to review plaintiff's medical records, but not to examine her, and then offer an opinion on her disability.

Settlement Discussions

The parties conducted a mediation, but no resolution was reached.

Result

Following the filing of trial briefings, the court conducted a bench trial. Applying the de novo standard of review when reviewing defendant's denial decision, the court entered judgment in favor of plaintiff and against defendant, ruling that the medical records demonstrated that plaintiff was unable to perform the substantial and material acts of her usual occupation, and was therefore entitled to disability benefits. The court concluded that plaintiff met the Plan's definition of disability. Finally, based on Plan language limiting the payment of benefits for certain conditions, the court determined that plaintiff was entitled to 24 months of disability benefits, the maximum allowed by the policy.

Other Information

The court noted that there was a "striking divide" between the opinions of the physicians hired by defendant to conduct "paper reviews" of the file and the opinions of plaintiff's treating physicians. While explaining that the court "does not accept the treating physicians' opinions over the paper reviewers' opinions as a matter of course," it noted that, despite defendant's assertions, the records contained "plenty of indications" that plaintiff's conditions worsened from "the time she was fit to work to the time that she was declared disabled." Following the court's decision, the parties reached a settlement regarding the attorney fees and costs incurred by plaintiff in the litigation. FILING DATE: April 17, 2015.