The Western District of Kentucky ruled in favor of a Baptist Healthcare physician, ordering Reliance Standard Life Insurance Company (Reliance Standard) to conduct a full and fair review of her claims for short-term and long-term disability (STD and LTD) benefits due to POTS.
Dr. April Halleron’s Disability Case
While employed with Baptist Healthcare, Dr. Halleron was diagnosed with postural orthostatic tachycardia syndrome (POTS), a condition linked with low blood pressure, fatigue, high pulse rates, and fainting. Concerned that she could no longer safely work as a physician, she submitted claims for STD and LTD benefits with Reliance Standard.
POTS is an autonomic nervous system disorder that affects blood flow and heart rate. People with POTS experience an increase in their heart rate upon standing up, which leads to dizziness, lightheadedness, fatigue, heart palpitations, and even fainting. The symptoms can make even simple tasks—especially ones that require standing or going from sitting to standing--like grocery shopping and showering difficult. For a physician, who is required to be attentive and alert at all times, suffering from POTS can be disruptive and dangerous and prevent them from performing their duties.
Despite the disabling nature of POTS, Reliance Standard denied both of Dr. Halleron’s claims. First, it concluded that her POTS was a preexisting condition making her ineligible for STD benefits. Next, her LTD claim — while not barred by a preexisting condition exclusion — was still denied after Reliance Standard determined that Dr. Halleron did not meet the Policy’s definition of total disability. Dr. Halleron then filed a lawsuit under the Employee Retirement Income Security Act (ERISA).
Court Rejects Reliance Standard’s Reasonings
After reviewing the parties’ motions for summary judgment, the Court ruled as follows.
- Dr. Halleron was deemed to have exhausted her administrative remedies.
Before filing a lawsuit, plaintiffs are ordinarily required to exhaust their administrative remedies by going through an appeals process with their insurance company. However, due to Reliance Standard’s failure to follow ERISA-mandated claims handling procedures, Dr. Halleron was deemed to have exhausted her administrative remedies and allowed immediate access to seek judicial review.
- Reliance Standard’s denials of Dr. Halleron’s STD and LTD claims were not “the product of a deliberate, principled reasoning process.”
Regarding the STD claim, the Court found that the denial was cursory at best and lacked a detailed analysis of how it determined Dr. Halleron’s POTS diagnosis was a preexisting condition. With respect to the LTD claim, the Court criticized Reliance Standard’s single-paragraph decision, which it said lacked substance, supporting evidence, medical analysis, and consideration of whether Dr. Halleron’s symptoms prevent her from performing her job duties.
The Court found that the denial merely recited Dr. Halleron’s medical history and completely failed to address her treating physician’s opinions. Consequently, the Court found both denials to be arbitrary and capricious.
Though the Court entered judgment in favor of Dr. Halleron, it chose to remand the case back to Reliance Standard as doing so is generally the appropriate remedy when there is a flaw with the integrity of the claim decision-making process. However, the Court also signaled it was inclined to approve a request from Dr. Halleron to have Reliance Standard pay her attorneys’ fees and costs by ordering the parties to brief the issue.
What You Should Know About Disability Insurance Claims & POTS
As disability insurance attorneys, our team at Dabdoub Law Firm often sees insurance companies deny valid short-term and long-term claims for claimants suffering from POTS. POTS is often misunderstood by insurance companies, leading to delays or denials in long-term disability insurance claims. The insurers often scrutinize the medical evidence saying it does prove the condition is impairing or suggest that while the claimant may have a diagnosis of POTS, it does not rise to the level of disability.
If you are suffering from POTS and dealing with a long-term disability claim, it is crucial to present strong evidence from your treating providers and any reports you have from independent medical evaluators. The evidence you submit to your disability insurance company should include objective testing like a tilt-table test, as well as documentation of your symptoms. Ideally, your doctor should document abnormal physical exam findings and personal observations that corroborate your reported symptoms.
Disability Insurance Companies Have Lawyers – Shouldn’t You?
Because this law firm was created to focus on disability insurance, we have developed expertise in this complex area of the law.
Our expertise in long-term disability claims means our clients have the backing of a law firm whose attorneys have:
- Expertise in submitting, appealing, and litigating disability claims;
- Fought all major disability insurance companies and know their tactics;
- Lengthy track record of success;
- Won major disability lawsuits that created good law; and,
- Recovered millions of dollars in disability benefits.
All our lawyers commit every day of their legal career to helping people get disability benefits from Reliance Standard, UNUM, MetLife, Prudential, Northwestern Mutual, Hartford, CIGNA, and others.
Because federal law applies to most disability insurance claims, we do not have to be located in your state to help. We represent clients nationwide.
Call the Dabdoub Law Firm to get experienced disability lawyers on your side. We can help with:
- Submitting a disability insurance claim;
- Appealing a long-term disability denial;
- Negotiating a lump-sum settlement; or
- Filing a lawsuit against your disability insurance company.
The firm represents clients nationwide with disability claims governed by federal law, even if we are not located in your state.
Call (800) 969-0488 or contact us online to speak with an experienced disability attorney. Pay no fees or costs unless you get paid.