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July 2016

Seattle Team Prevails on Motion for Judgment on an ERISA Matter Under a De Novo Standard of Review

Gordon & Rees Seattle partner Sarah N. Turner and senior counsel Brittany F. Stevens won a judgment for the defendant insurer in the United States District Court, Western District of Washington on a disability benefit claim. The lawsuit arose out of the denial of the plaintiff’s claim for long-term disability benefits under a fully insured disability benefit plan.

The plaintiff had a long history of back pain, and he stopped working when he claimed that various accommodations at work were no longer sufficient to relieve his pain. He submitted various medical records and self-reports of pain in support of his claim for benefits. The plaintiff’s records also described a variety of different physical activities he participated in including exercising an hour on his bike every other day, strenuous StairMaster workout, and pushups. He also participated in an off-road biking excursion, a week-long fishing trip, an eight-hour boat ride, and he regularly gardened for more than three hours at a time.

The insurer arranged for two independent peer reviews by occupational medicine specialists, as well as an Independent Medical Evaluation, which all concluded that the plaintiff was not disabled under the terms of the Plan. After an evaluation of the medical records and these independent reviews, the insurer concluded that the plaintiff was able to perform the material duties of his own occupation. The insurer also found that there was not sufficient objective evidence of his disability, and the plaintiff’s self-reported pain and claims of physical limitations were questionable given the plaintiff’s ability to perform a variety of physical activities. The insurer also considered the Social Security Administration’s determination that the plaintiff was eligible for disability benefits, but noted that the definitions of disability were different and that the Social Security Administration’s decision was based on different evidence.

Evaluating the case under a de novo standard of review, the Court found that the plaintiff was able to perform the physical material duties of his job and was therefore not disabled under the terms of the policy. The Court particularly noted the evidence showing the plaintiff’s activity level, which undermined his reports of debilitating pain. The Court also noted that any claim that the plaintiff was not able to perform the cognitive material duties of his occupation was unsupported by the evidence. In entering judgment in favor of the insurer, the Court noted three independent medical reviews obtained by the insurer during the review period, including an in-person Independent Medical Evaluation. After an extensive review of the available medical records, each of these physicians concluded that the plaintiff was capable of performing the material duties of his own occupation. Notably, the Court placed more weight on the decisions of these reviewers than on a Social Security Administration award of benefits because the independent reviewers had more detailed knowledge of plaintiff’s physical activities and abilities during the period of alleged disability.

To read the opinion, click here.

Brittany F. Stevens
Sarah N. Turner



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