A federal US district court (Northern District of California, San Jose) in an ERISA Long Term Disability case decided a prior finding of disability by the insurance company is an important factor. The Court also decided that a Functional Capacity Exam (FCE) is a factor in determining the case, despite Prudential’s attempt to discount the exam’s findings.
Prior finding of disability is a factor in favor of the plaintiff when an insurer terminates LTD benefits
The court’s ruling holds that a prior finding of disability by the insurer is a significant factor that weighs in favor of the plaintiff. Since Prudential first decided the Plaintiff, a Drug Safety Operations Manager at Jazz Pharmaceuticals (“Jazz”) in Palo Alto, California, was disabled, and even paid short and long term disability benefits for 5 months, that is must show some significant medical change to terminate her benefits.
The Court then presumes Prudential relied on a significant change in the circumstances of her condition in order to recant its previous approvals and expects Prudential to provide some evidence of Gallegos’ medical progression at the time of its termination of LTD benefits. See Bledsoe v. Metropolitan Life Ins., 90 F. Supp. 3d 901, 910 (2015). However, a review of the record reveals no such significant change. See Saffon v. Wells Fargo & Co. Long Term Disability Plan, 522 F.3d 863, 871 (9th Cir. 2008) (noting that the defendant failed to “explain why further degeneration is necessary to sustain a finding that [claimant] is disabled” after defendant had been paying the claimant long-term disability benefits for a year”); Schramm v. CNA Fin. Corp. Insured Grp. Ben. Program, 718 F. Supp. 2d 1151, 1164 (N.D. Cal. 2010) (“Although Defendant did not need to prove a material improvement in Plaintiff’s condition to defeat her entitlement to benefits, her lack of consistent, marked progress is probative of her continuing disability.”). Accordingly, Prudential’s prior finding of disability weighs in favor of finding disability.
Functional Capacity Exams Are Factors When Determining Disability in LTD cases
The plaintiff underwent a functional capacity exam. The exam consisted of the plaintiff reporting subjective complaints, but also observations and test by the examiner. Prudential argued the Court should ignore the results of this exam because it was entirely based on self-reported complaints of pain. The Court did not find this to be true. There were observations by the examiner, pinch and grip tests. The examiner noted the plaintiff was giving full physical effort.
In addition, the court noted it rejects attempts to ignore self-reported symptoms. Thus, even self-reported complaints of pain and symptoms must be considered.
In addition, courts have rejected attempts to ignore self-reported symptoms such as that of Prudential’s here. See, e.g., Gilmore v. Liberty Life Assurance Co. of Boston, 2014 WL 1652048, at *6 (N.D. Cal. Apr. 24, 2014) (overturning denial where administrator’s doctors noted “plaintiff’s reports of pain” but “disregarded those self-reports”); Stout v. Hartford Life and Acc. Ins. Co., 58 F. Supp. 3d 1020, 1030 (N.D. Cal. 2013) (overturning denial where administrator’s doctors ignored “cumulative effect” of side-effects including musculoskeletal pain); Moody v. Liberty Life Assur. Co. of Boston, 595 F. Supp. 2d 1090, 1099 (N.D. Cal. 2009) (overturning denial where administrator’s doctors ignored “severe neck, arm, and back pain” that had been consistent “over a long period of time”). Accordingly, the opinions of Gallegos’ treating doctors and the functional capacity evaluations support that Gallegos was “more likely than not” disabled under the terms of the Jazz Pharmaceuticals Long- Term Disability Plan.
The sporadic nature of Lupus flares prevents consistent work capacity
The court held the sporadic nature of lupus flare ups can prevent a person from being able to work consistently. A claimant may be stable at any given time, but a flare up can knock that person out, sometimes for a few weeks. A full time employer just can’t have that sort of unpredictability and inconsistent attendance.
While I did not handle this case, and this is just a summary of the case, if your benefits were denied or terminated, give us a call immediately. Once your benefits are denied or terminated, and they send you a letter, the clock starts ticking and you only have a few months to file an appeal. If you don’t file the appeal on time, your rights may be lost forever.
This case is called Gallegos vs Prudential and is linked below.Gallegos v. Prudential Northern District of California