District Court bounces denied disability claim back to plan administrator for full and fair review
Youngstown, OHShelley Westfall and her son both worked at the same WalMart distribution center. Her son died while working there, and Shelley could not bring herself to go back to work at that location. When her long term disability benefits were discontinued, she filed a lawsuit alleging that her denied disability appeal had been wrongly decided because the plan administrator refused to consider evidence of her disabling emotional state.
She won, at least to the extent that her case was remanded to the plan administrator for a full and fair review. That, in itself, is rare and remarkable.
Cherry-picking medical evidence
Long term disability insurers, like Liberty Life Assurance Company of Boston, a member of the Liberty Mutual family of companies and the defendant in this lawsuit, are notorious for denying long term disability benefits for conditions like depression, chronic pain or fibromyalgia, where the symptoms are necessarily self-reported.
At various times, Shelley Westfall described herself as not depressed, but "down" and broken hearted. Her life began to unravel with the failure of her marriage and periods when she could not get out of bed. Her psychiatrist described her as suffering from major depression and complicated grief. Her primary care physician added a diagnosis of emotional lability, a condition characterized by excessive emotional reactivity and frequent changes or swings in emotions and mood. That diagnosis supported her psychiatrist's finding of major depression.
The plan's medical reviewer, however, relying exclusively on a file review, disputed the treating physician's diagnosis of major depression and failed to address the issue of emotional lability. He concluded that Ms. Westfall was not disabled under the terms of the plan. The plan then denied her long term disability claim.
Getting past the arbitrary and capricious standard
Courts have typically deferred to the judgment of plan administrators in their decisions about benefit eligibility - bad news for workers who bring wrongfully denied disability claims. Things may be changing, though, especially as courts have begun to grapple with the conflict of interest inherent when a defendant LTD administrator both determines whether a claimant is eligible for benefits and pays those benefits.
In Ms. Westfall's situation, the plan administrator's decision to simply disregard the treating physicians' diagnoses was apparently a bridge too far. It's not over for Shelley Westfall yet, but at least she may get a fair hearing.
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