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California Court finds Anthem Wrongly Denied LTD Benefits For a Vice President suffering from Psychiatric Issues

A California Court finds Anthem wrongly denied LTD benefits for a Vice President suffering from Psychiatric Issues. Mr. Kopicko, a 47-year-old man, in San Diego, California, worked as Vice President of a company until he was forced to cease work in September 2017 due to major depressive disorder (“MDD”) and agoraphobia. He was also diagnosed with a generalized anxiety disorder (“GAD”), and post-traumatic stress disorder (“PTSD”).

Mr. Kopicko filed for long-term disability (“LTD”) in December 2017 due to MDD, and his claim was subsequently denied. He then appealed the denial of his claim nearly a year later.

In March 2019, Mr. Kopicko filed a supplement to his appeal, which included complete medical records from one of his doctors, and a report from a forensic psychiatrist who had conducted an independent medical examination (“IME”) on him. This IME indicated the MDD diagnosis caused Mr. Kopicko to be “severely disabled to the point where he cannot leave the house or function at his previous job.”

Upon receipt of these records, Anthem’s reviewing doctor reviewed Mr. Kopicko’s medical files. Anthem’s reviewing doctor concluded that from November 2017 through May 2018, and from March 2019 to present, Mr. Kopicko was experiencing psychiatric impairment to such a level that prohibits him from being able to work in even simple tasks.

Based on Anthem’s reviewer’s report, Anthem granted LTD benefits from November 2017 through May 2018, and denied all LTD benefits thereafter. Anthem found that Mr. Kopicko was not disabled from May 2018 through March 2019, but became disabled once again after March 2019.

In other words, Anthem denied Mr. Kopicko’s benefits beyond May 2018 because it claimed there was a window of time during which Mr. Kopicko no longer was disabled. As a result, it claimed he no longer covered under the policy, despite Anthem recognizing he was disabled only a few months later.

Mr. Kopicko appealed Anthem’s denial of benefits beyond May 2018. Anthem denied Mr. Kopicko’s second appeal.

In a case like this, it begs the question, what improved in Mr. Kopicko’s condition in May 2018, but then worsened in March 2019?

The answer, the court found, was nothing. The court noted that Anthem’s reviewing doctor’s opinion that Mr. Kopicko went from being disabled to not disabled, to then again disabled due to his psychiatric diagnoses is problematic for two primary reasons:

  • The March 2019 date is only relevant because it was the date of his initial IME report.
  • Anthem cherry picked his medical records to interpret them as an improvement

The court pointed out that mental illness cannot be substantiated the way a physical illness can. There are no objective lab tests to verify a mental illness. Nonetheless, the medical records in this case supported mental illness throughout the time being questioned.

Thus, the court held that Mr. Kopicko met his burden to show he was disabled from May 2018 to March 2019 and was entitled to LTD benefits during that time.

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