Employer Failed To Meet Its Obligations to the Beneficiary by Not Obtaining Readily Available Information in Short Term Disability Review

When employees in Chicago make a claim for short-term or long term disability benefits under an employer sponsored ERISA disability plan, the primary responsibility for providing medical proof of disability rests on the claimant.  Anything that the claimant submits to the insurer, such as medical records, activities of daily living forms, Social Security award letters etc. will become part of the “the record.”  The record is extremely important because when and if a claim has to go to litigation, the case will be dependent on what is in the record (or perhaps more importantly, what is not in the record).  Clients are often surprised to learn that, with limited exceptions, once litigation commences they cannot add new medical documents and office notes to the record. While most disputes occur once there is a claim for long term disability benefits, the review of a claim for short-term disability can be critical because it leads to a claim for long term disability, or in some cases, the long term disability plan makes full eligibility for short-term disability a condition to receive the long term disability benefits.

Oftentimes, claimants do not have their physical medical records on hand, so instead they equip the insurer with information about their treating physician and that physician’s contact information.  When a plan administrator possesses this information it cannot be willfully blind to that medical information that may confirm the claimant’s disability and where there is no other evidence already in the record to refute that disability. Nonetheless, plan administrators have put on their blinders when anything less than actual medical records are submitted.  This is what happened in Harrison v. Wells Fargo Bank, N.A., No. 13-2379, 2014 U.S. App. LEXIS 22932 (4th Cir. Dec. 5, 2014).

In Harrison, Ms. Harrison was undergoing multiple surgical procedures for a large mass in her chest that was causing her pain and tracheal compression.  She was originally approved for short-term disability from the time of her bronchoscopy procedure (June 9, 2012) through her arguable recovery from a thyroidectomy procedure (September 10, 2011).  However, she was denied benefits between her September 10, 2011 procedure and her next surgical procedure which was on October 31, 2011.  Yet, the plan agreed that she was eligible for benefits after October 31, 2011.  During the short period in dispute, the plan administrator deemed Ms. Harrison “healed” and was capable of returning to work; however, she was also suffering from PTSD from the recent loss of her husband.  She provided the plan administrator with her doctors’ contact information, particularly her psychologist’s contact information. However, Wells Fargo only provided its contracted peer reviewing physician with Ms. Harrison’s primary care physician’s contact information.  The peer reviewer indicated to the plan administrator that the record was not sufficient to render a decision on her claim.  But, the plan went ahead and denied her short-term disability a second time.

In ruling against Wells Fargo Bank, the United States Court of Appeals for the Fourth Circuit considered briefing submitted by the Department of Labor and found that the plan administrator erred in denying employee Mr. Harrison’s claim for short-term disability benefits without contacting her treating psychologist, despite having the psychologist’s contact information and a signed release from Harrison readily available. In order to avoid the problem that arose in the Harrison case, our firm strives to obtain any and all relevant medical documents or records for you and submit them as attachments to your appeal.  This serves two purposes: (1) it ensures your important records become a part of your claim file; and (2) it is patent evidence that the plan administrator must consider prior to reaching its decision.  While disputes over what the administrator should have obtained and considered can be won, it is always best to eliminate as many issues from your claim as possible.

If you need to make a claim for short-term or long term disability benefits, and need to know how to give yourself the best chance of having your claim approved, contact an experienced ERISA attorney.