A Missouri federal court recently found LINA wrongfully stopped paying a healthcare administrator’s long-term disability (LTD) benefits. Melanie Lapidus enjoyed a successful career as BJC Healthcare’s Vice-President of Medical Benefits until two ruptured discs in her back eventually led to a diagnosis of degenerative lumbar scoliosis.
At first, LINA approved Ms. Lapidus’ claim for long-term disability benefits. However, just five months later, LINA changed its mind and told Ms. Lapidus it was now denying her claim.
Twice, Ms. Lapidus appealed LINA’s decision to terminate her benefits and provided the following, additional evidence showing that she was still disabled:
- Letters from her treating doctors;
- Updated medical records from her treating doctors; and
- A Functional Capacity Evaluation (FCE).
LINA denied both appeals, relying more on their own doctor’s opinions who were asked to review Ms. Lapidus’ medical records. Then, Ms. Lapidus and her attorneys were forced to file a lawsuit against LINA.
The Court’s Review of Ms. Lapidus’ Claim
Like most claims for disability benefits, Ms. Lapidus’ claim was governed by the Employee Retirement Income Security Act of 1974 (ERISA). Generally, if you are eligible for disability benefits through your job, it is likely governed by ERISA.
ERISA Disability Insurance Standard of Review
Most disability policies contain discretionary language. This means insurance companies, including LINA, have discretion to determine if someone meets their definition of disability.
Under ERISA, if there is discretionary language, the court will apply an arbitrary and capricious standard of review. Under this standard, the court can only rule in your favor if it finds the insurance company had no reasonable basis to deny benefits. This is a difficult standard to meet.
Here, the insurance company did not argue its disability policy contained the necessary discretionary language. Therefore, the court did not need to give deference to LINA’s decisions to terminate Ms. Lapidus’ benefits. This greatly increased her chances of success.
The Court’s Decision
The court found LINA’s decision was wrong because:
- An insurer who first approves LTD benefits, then later terminates them, must show a significant change in the claimant’s condition;
- Ms. Lapidus’ FCE showed that she lacked the ability to sit for more than one-third of the work day, as required by any sedentary job; and
- The evidence demonstrated that Ms. Lapidus’ pain is persistent and disabling.
In addition, the court stated that while pain is difficult to quantify, it can evaluate a claimant’s course of treatment regarding that pain. Here, the court concluded that the opinions of Ms. Lapidus’ treating doctors corresponded with her reports of persistent pain and with the treatments she received. Therefore, Ms. Lapidus remained disabled and eligible for benefits.
Help from an Attorney with Expertise in Disability Insurance
Disability insurance law is complicated. If your claim for long term disability benefits was denied or being delayed by an insurance company, it is important to get help from a lawyer with expertise in disability law.
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- Our lawyers specialize in disability insurance;
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Because federal law applies to most disability insurance claims, we do not have to be located in your state to help.
Dabdoub Law Firm represents clients nationwide with:
- Submitting a disability insurance claim;
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Call today to speak with a disability insurance attorney. No fees or costs unless clients are paid.
