After working for a law firm as a healthcare attorney for more than seven years, Amanda Foster began having intractable migraine headaches, so she stopped working. She received long term disability (LTD) benefits from Principal Life Insurance Company (Principal) from September 4, 2013, until they were terminated effective December 9, 2014.
Foster filed two administrative appeals and submitted additional medical records. After Principal paid numerous physician reviewers, it denied her claim and found she was not disabled according to the meaning of her disability insurance policy. She then filed an ERISA lawsuit. That was decided in favor of Principal, so she appealed that denial to the Fifth Circuit Court of Appeals.
In Amanda Foster v. Principal Life Insurance Company, the Fifth Circuit upheld the District Court’s denial of LTD benefits to Foster. It found substantial evidence supported Principal’s denial. Final Fifth Circuit decision: Appeal Denied.
In support of Foster’s claim that she was unable to work in her own occupation due to her migraines, she provided Principal her medical records as well as an attached report from her neurologist that said he advised her to “stop working” due to her headaches.
Principal hired four physicians to review Foster’s medical records. The first two doctors agreed that her daily migraines would keep her from working on a full-time basis, so Principal hired two more reviewers. The new reviewers both reported that her medical records did not support a finding of disability.
One reviewing physician stated that there was “no clinical evidence that demonstrates that Ms. Foster is functionally impaired.” He concluded that she could perform her sedentary job full-time.
Foster’s Administrative Mandatory Appeal
Foster filed a mandatory appeal with Principal. She submitted new medical records, test results for an MRI and EEG that were normal, report of an independent medical exam (IME), and a new letter from her neurologist who repeated his earlier assessment that “she was advised to stop working.”
Again, there was conflict with Foster’s treating physicians and Principal’s reviewing physicians. In addition, Principal’s surveillance on her showed her doing routine activities like grocery shopping and picking up her children. She also maintained a monthly online blog which showed her to have an “undiminished ability to write, focus, and concentrate as would also be required in her occupation.” Based on this evidence, her appeal was denied.
Foster’s Administrative Voluntary Appeal
A voluntary appeal followed the denial of her mandatory appeal. Foster submitted essentially the same evidence, with the independent medical examiner giving his opinion that she could not fulfill her duties as an attorney.
Principal again hired reviewing physicians and ordered an independent neurological exam (INE). That examiner found she had psychological problems, but determined there should be no impairment in her ability to carry out her tasks.
Since she had exhausted her administrative remedies, she filed an ERISA lawsuit alleging that Principal had abused its discretion by denying her LTD benefits. The lawsuit was decided in Principal’s favor by the U.S. District Court for the Eastern District of Louisiana. Foster appealed that decision to the U.S. Court of Appeals for the Fifth Circuit.
Court of Appeals Standard of Review
The Court of Appeals conducted de novo review of the district court’s decision which means it reviewed “the plan administrator’s decision from the same perspective as the district court” which was to determine if Principal had abused its discretion in denying Foster’s claim.
The Court explained that “Under the abuse of discretion standard, if the plan fiduciary’s decision is supported by substantial evidence and is not arbitrary and capricious, it must prevail.” It added that this is true “Even if an ERISA Plaintiff supports his claim with substantial evidence, or even with a preponderance, he will not prevail for that reason… rather, it is the plan administrator’s decision which must be supported by substantial evidence, and, if it is, the administrator’s decision ‘must prevail.'”
The abuse of discretion standard of review is an example of why it is so difficult for claimants to win their case against disability insurance companies in the courts. The deck is stacked against the claimant from the beginning. At Dell & Schaefer, we always do whatever we can do legally to convince the court to apply a de novo standard, which means the courts do not have to give deference to the decision of the plan administrator.
Appeals Court Finds Substantial Evidence Supported Principal’s Finding that Foster Was Not Disabled from Performing the Duties of Her Own Occupation
There were conflicting medical reports; however, all reviewing physicians were given a list of Foster’s specific duties as a healthcare lawyer. The Appeals Court acknowledged that Principal had a “light burden,” but concluded it met that burden.
Evidence given by the psychologist who conducted the INE was substantial. He did assess a range of skills Foster needed to use in her own occupation and opined she was not disabled from performing them. That was substantial enough evidence for the Court of Appeals to uphold that ruling.
Substantial Evidence Supported That Her Migraines Did Not Interfere with Her Ability to Work
Foster claimed that Principal abused its discretion by requiring objective evidence that she suffered from migraines. The Court disagreed. It said that it wasn’t objective evidence of the migraines Principal requested, but instead, for evidence that whether and to what extent those migraines functionally impaired her and interfered with her ability to perform the duties of her own occupation. Since there was substantial evidence that the migraines did not interfere with her ability to perform her job duties, Principal did not abuse its discretion by its LTD denial.
This case was not handled by our office, but if you have any questions about issues raised in this appeal, or any other aspect of your disability claim, contact one of our disability attorneys at Dell & Schaefer. We offer a free consultation.