Home > Blog > Blog > Long Term Disability > District Court Finds Insurer’s Termination of ERISA-Governed Long Term Disability Benefits Was Not Arbitrary or Capricious

District Court Finds Insurer’s Termination of ERISA-Governed Long Term Disability Benefits Was Not Arbitrary or Capricious

In Bernitz v. USAble Life & Fullscope RMSNo. 22-CV-10712-DJC, 2024 WL 3106249 (D. Mass. June 24, 2024), Massachusetts District Judge Denise J. Casper granted summary judgment to Defendants finding that USAble Life did not abuse its discretion by terminating Plaintiff’s ERISA-governed long-term disability (“LTD”) benefits after finding Plaintiff’s condition had improved to allow full-time light or sedentary work.

Plaintiff was employed as a Senior Vice President of Corporate Development at Synta Pharmaceuticals when he stopped working in June 2014 due to back pain and submitted a claim under his group LTD policy. Plaintiff’s certifying physician noted MRI results reflecting “class 5” physical impairment due to severe degenerative disc disease. USAble Life approved Plaintiff’s LTD claim and began paying benefits. In April 2016, while on claim, Plaintiff underwent his sixth back surgery. In October 2017, USAble Life ordered a medical review of Plaintiff’s records, which found that Plaintiff continued to be impaired from performing full-time light or sedentary occupations secondary to his multiple back surgeries and their poor results.

Two years later, in December 2019, USAble Life terminated benefits after it had ordered both surveillance and another medical review which found that Plaintiff’s condition had improved, he had lost 70 pounds, was active, and was exercising with a personal trainer doing cardio and free weights. Plaintiff had also been traveling both within and outside the U.S., was driving, walking half a mile, and taking college classes. USAble Life also learned that in August 2018, a Social Security Administrative Law Judge had denied Plaintiff’s application for SSDI benefits, citing the similar activities and evidence.

Plaintiff appealed submitting a functional capacity evaluation (“FCE”), a neuropsychological evaluation (“NP evaluation”), letters from his treating providers and statements by Plaintiff and his wife all supporting ongoing disability. USAble Life upheld its termination decision on appeal after two medical reviewers found numerous inconsistencies between the results of the FCE and the medical records including reports of his weight loss, exercise activity and international travel including a safari in Africa. USAble Life’s medical reviewers also disagreed with the interpretation of the NP evaluation and found that the results did not reflect a debilitating neurocognitive impairment. The instant lawsuit followed.

On cross-motions for summary judgment, the Court reviewed the claim under the arbitrary and capricious standard, applying little weight to the existing structural conflict of USAble Life both adjudicating Plaintiff’s claim as well as bearing responsibility for paying out benefits, finding that USAble Life had taken sufficient steps to insulate its claims determination process. As to the merits of the case, the Court discerned no error by USAble Life in its decision to terminate benefits or uphold that decision on appeal. The Court found that USAble Life properly terminated benefits based on substantial evidence of improvement including the ALJ denial of SSDI benefits, significant weight loss and the medical benefits of same, domestic and international travel, and personal observations of investigators. In light of the reported inconsistencies in the FCE and analysis of the NP evaluation, the Court also found that USAble Life had ample basis to rely on the opinions of its medial reviewers and afford little weight to the testing results. As such, the Court concluded that USAble Life’s handling of Plaintiffs’ claim and appeal was not arbitrary and capricious.

If your insurer has denied or otherwise limited your disability insurance claim, contact us for assistance.


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*Please note that this blog is a summary of a reported legal decision and does not constitute legal advice. This blog has not been updated to note any subsequent change in status, including whether a decision is reconsidered or vacated. The case above was handled by other law firms, but if you have questions about how the developing law impacts your ERISA benefit claim, the attorneys at Roberts Disability Law, P.C. may be able to advise you so please contact us.

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