In an opinion issued on September 4, 2014 by the United States Court of Appeals for the Sixth Circuit, an Appeals Court upheld a District Court’s opinion that awarded Ms. Ashima James long term disability benefits. Despite Liberty Life’s two independent medical examinations and at least 4 “independent” file reviews, both Courts concluded that James produced a sufficient amount of evidence to qualify for disability benefits under the Policy.

Facts of the Case

Ashima James was a full time employee with DTE Energy. As such she was insured under the DTE Group Disability Income Policy which was issued by Liberty Life. This policy provided for long term disability benefits if one became disabled. Now like most disability insurance policies, what it means to be disabled under the policy will change after a certain amount of time. During the first 24 months, in order to be considered disabled one must be “unable to perform the Material and Substantial Duties of his regular occupation…”. After 24 months of benefits, in order to be eligible for continued benefits, one must then be “unable to perform, with reasonable continuity, the Material and Substantial Duties of Any Occupation.” Such “Any Occupation” is one in which the claimant “is or becomes reasonably fitted by training, education, experience, age, physical and mental capacity” to perform.

Unfortunately for Ms. James, on August 4, 2011 she was a passenger in a vehicle that was rear-ended by another vehicle. Due to the accident she was taken to an emergency room and followed up with a visit to her primary care physician the next day. Ms. James was initially diagnosed with strain to her thoracic spine and chest wall, contusions and strain. She would be later diagnosed with shoulder pain with limited movement, thoracic myofascial pain, right shoulder labral tear, supraspinatus tendonitis, and cervical degenerative arthritis with moderate to severe foraminal stenosis and mass effect on the cord. Furthermore, her psychiatrist ultimately diagnosed her with major depressive disorder, recurrent, severe without psychotic features, and generalized anxiety disorder.

Due to her conditions, Ms. James applied for disability benefits. Unfortunately for her, Liberty Life denied Ms. James’ claim for long term disability benefits, finding that she did not meet the own occupation standard under the policy. In support of its decision, Liberty Life pointed to two Independent Medical Examinations (“IMEs”) it had conducted and two doctor file reviews who did not personally examine Ms. James but instead reviewed her medical records. Liberty Life also utilized an occupational analysis and vocational review. As one may expect, the reviews commissioned by Liberty Life all agreed that Ms. James was not disabled under the terms of the policy. As such, Liberty Life denied her claim.

As required by ERISA, Ms. James filed a timely administrative appeal. While reviewing this appeal, Liberty Life commissioned two additional doctor file reviews which also agreed that Ms. James’ documentation did not support impairment. As such, Liberty Life denied James’ appeal and a Lawsuit was filed. Fortunately for Ms. James, the District Court found “that the preponderance of the evidence in the administrative record supported a finding that James was disabled from performing her regular occupation.” That Court thus awarded benefits for the period of February 24, 2012 through February 24, 2014. That Court found that “principal weakness of Liberty’s evidence against disability is that the doctors who reviewed James’ file did so from either a physical pain/rehabilitation perspective or a psychological perspective, not both.” The District Court held that while “neither her physical nor psychological impairments, standing alone, [were] disabling,” James’s disability claim was validated by the comorbidity of her condition.”

Liberty Appeals the District Court’s Ruling

Due to the fact that it was unsuccessful at the lower court, Liberty Life appealed the District Court’s decision. With its appeal, Liberty Life argued that treating physicians opinions are not entitled to any special weight. It thus argued that the District Court gave special treatment to Ms. James’ treating physicians and discounted the opinions of the IME doctors and the paper reviewing doctors. Unfortunately for Liberty Life, the Court of Appeals however noted that the district court’s “explicit reason for giving less weight to the file reviewers’ opinions was that they took piecemeal approaches to their evaluations, instead of holistically viewing James’s comorbid conditions.” Thus the Appeals Court ruled that the district court did not improperly weigh the various physician opinions. Furthermore, the Appeals Court found that the “proof produced by James established by a preponderance of the evidence that she was entitled to long-term disability benefits under the regular occupation standard of the Policy, first, because the weight of the evidence favors a finding that James was disabled, and second, because James produced ample subjective and objective evidence that she was unable to work.” As such, the Court of Appeals confirmed the lower court’s decision, and Ms. James was again awarded benefits.

If you have an active claim with Liberty Life, or if you have been denied benefits by Liberty Life or any disability insurance provider, please do not hesitate to speak with a Lawyer at Dell & Schaefer. Disability lawyers are available at your convenience to have a complimentary phone conference.

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