Sixth Circuit Rules in Favor of LTD Claimant Following Nondeferential Review of Administrative Record

An information technology manager with debilitating lower back pain was denied long-term disability benefits. Although the claimant logged numerous visits with his primary care provider and multiple specialists, he failed to get an updated MRI, declined aquatic therapy, and elected not to see one recommended specialist. Thus, the claims administrator determined he was not in the “regular attendance” of a physician, as required by the plan, because he failed to seek “the most appropriate [treatment] to maximize medical improvement.” It further determined that his ability to perform sedentary work meant he could perform his regular occupation, even though his doctor concluded that cognitive impairment from his use of prescribed opioids made him incapable of performing his regular duties. The claimant exhausted administrative appeals, then filed suit. The trial court upheld the denial, and the claimant appealed.

According to the Sixth Circuit, the claimant was required to prove by a preponderance of the evidence that he was disabled as defined by the plan. The court applied de novo review, giving “proper weight to each expert’s opinion” without deference or presumption of correctness to prior decisionmakers. Treating physician opinions were not given more weight than those of non-treating physicians. The court noted that the claimant was obligated to obtain care appropriate for a totally disabled person but was not required to pursue prohibitively expensive, experimental, risky, or painful treatments. Finding that the claimant “pursued a quantum of treatment one would expect of a person who is totally disabled” and that the record offered little or no evidence that the treatments not pursued would have improved the claimant’s health, the court concluded that the regular attendance requirement was satisfied. Further, because the claimant’s doctor found that the long-term use of prescription opioids impacted his ability to perform the cognitive tasks required by his job, the court held that he had proved by a preponderance of the evidence that he was disabled from his regular occupation. Determining that no further fact-finding was necessary, the court awarded the claimant 24 months of benefits.

EBIA Comment: It is uncommon for an appellate court to directly award benefits instead of remanding for further administrative proceedings. This decision highlights the importance of developing a full administrative record and objectively supporting all inferences and conclusions. This case is also instructive as to how claims administrators should weigh the opinions of treating physicians, non-treating physicians, and other experts when making benefit determinations. For more information, see EBIA’s ERISA Compliance manual at Sections X.E (“Special Issues in Describing and Administering Benefits”), XXXV (“Claims Procedures for Disability and Other Non-Health Claims”), and XXXVI.C (“Standard of Judicial Review Applied to Benefit Decisions Under ERISA Plans”).

Contributing Editors: EBIA Staff.