We often hear our clients say, “They denied my claim even though…” You can fill in the rest of the sentence with a number of different things, i.e. “even though… the government says I am disabled,” “even though… all my doctors say I am disabled,” “even though… workers' compensation says I am disabled,” etc. Our response is always the same. ERISA is unfair, and all the “even though” statements in the world while making logical deductions or inferences will not win your case.
A new case involving a life insurance plan with a disability benefit in Ohio is a great illustration of why even though is not enough. In Smith v. ReliaStar Life Insurance Co., SD Ohio 2018, Mr. Smith was found to be disabled from performing any occupation due to chronic back problems and pain, heart problems, and fibromyalgia by the Social Security Administration. However, his treating physician filled out a form in which he stated that Mr. Smith was disabled from his own occupation but not disabled from performing any occupation. This could have been for a multitiude of reasons, but more than likely, it happened as a result of the treating physician not being familiar with all of the job duties for which Mr. Smith could be vocationally qualified to perform.
And, of course, guess which piece of evidence ReliaStar Life Insurance Co. relied on to deny this claim?
The District Court ruled against Mr. Smith and granted judgment in favor of ReliaStar
“even though” the Social Security Administration made a vocational determination that Mr. Smith was not qualified to perform any gainful occupation
“even though” Mr. Smith's treating doctor was not familiar with every occupation in the nation for which Mr. Smith was qualified to perform based on his past education, training and experience.
The District Court further reinforced its decision upon the “administrative record” which prevented new evidence during litigation. The court noted only the evidence that was provided during the claim process would be considered, and that was all that the court was reviewing in this instance. Once the claim process was completed, the administrative record was formed. That alone would be the basis of the court's decision.
Perhaps here, there was no evidence presented during the claim process, noting that the treating physician's statement form was not a good basis for the decision because the treating doctor was not a vocational expert.
Perhaps, there was no effort to have the treating physician explain his opinion.
Regardless, in this instance “even though” was not enough.
Based on this “administrative record” concept and, given that “even though” is not enough, when do you think would be the best time to obtain an attorney? During the claim process or after the claim record closed? If I was disabled, I can tell you there is only one good answer.
Call our ERISA attorneys in Alabama and Mississippi for long-term disability, short -term disability, life insurance, pension and retirement claims today to ensure that you aren't stuck saying “even though…”