District Court Finds LINA Improperly Denied Plaintiff’s Long Term Disability Claim, After Awarding Short Term Disability Benefits Under the Same Definition of Disability

In Reynolds v. Life Insurance Company of North America, No. C21-1424 TSZ, 2023 WL 6541328 (W.D. Wash. Oct. 6, 2023), Washington Western District Judge Thomas S. Zilly granted judgment to Plaintiff and reversed Defendant’s denial of her claim for long-term disability benefits, concluding that Plaintiff demonstrated the disabling nature of her medical conditions and entitled to LTD benefits under both the “own occupation” and “any occupation” disability definitions in the policy.

Beginning in 2006, Plaintiff was employed as a Bioinformatics Engineer for Affymetrix, and a participant in their employee benefit plan, which included a policy of short-term disability (“STD”) and long-term disability (“LTD”) insurance issued by Defendant Life Insurance Company of North America (“LINA”). In 2012, Plaintiff was diagnosed with multiple sclerosis, and post-traumatic stress disorder (“PTSD”) in 2017. Additionally, Plaintiff had a history of depression and was further diagnosed with anxiety, fibromyalgia, migraine headaches, asthma, and hypothyroidism.

The record reflects that Plaintiff took three months of STD in January 2014, while still employed by Affymetrix. Thereafter, her employer agreed to a reduction in work hours (from full-time to 30 hours per week). Plaintiff stopped working altogether in November 2015, but did not pursue any disability benefits until January 2018, when she first applied for Social Security Disability Insurance (“SSDI”). Following several appeals, an SSA Administrative Law Judge determined Plaintiff had been disabled since January 1, 2016.

Plaintiff initiated her claim for benefits with LINA on October 7, 2019, initially listing October 15, 2012, as the date she was unable to work. LINA denied the claim as the policy did not become effective until January 1, 2014. Plaintiff later amended her date of disability and informed LINA she was seeking both STD and LTD benefits as of November 19, 2015, when she stopped working at Affymetrix.

On May 20, 2020, LINA approved STD benefits from December 5, 2015 through May 20, 2016, and requested further medical information to extend benefits to the six-month maximum. LINA denied Plaintiff’s LTD claim on October 6, 2020, asserting that Plaintiff’s “symptoms were not consistent with her functional inability from a physical and psychiatric viewpoint that would preclude her from performing the essential duties of her own occupation[.]” LINA upheld its LTD decision on appeal.

On cross-motions for judgment, the Court found that that Plaintiff had satisfied her burden of demonstrating entitlement to LTD benefits. First, the Court found LINA’s award of STD benefits was relevant because the Policy’s standard to receive STD benefits was identical to the standard for receipt of the first 24 months of LTD benefits. The court did not find sincere LINA’s assertion that it approved STD benefits “as a stop gap measure” because she was now eligible for STD based on the revised disability date and had not assessed the merits of Plaintiff’s claimed impairment. It noted that LINA’s approval letter stated that the decision was “based on the current medical information on file.” As such, the Court concluded that LINA’s approval of STD benefits must be construed as a determination that Plaintiff was disabled as defined by the Policy for purposes of the first 24 months of LTD benefits.

With regard to benefits beyond 24 months, under the “any occupation” standard, the Court noted that LINA did not argue that Plaintiff’s medical condition had improved and documented that Plaintiff’s treating providers continued to support impairment. The Court also found that the SSA determination further supported ongoing disability and concluded that Plaintiff demonstrated entitlement to “any occupation” benefits. The Court directed LINA to pay Plaintiff LTD benefits to the Policy’s maximum benefit duration absent a showing of improvement in her medical condition such that she is no longer disabled within the meaning of the Policy.

If LINA or your insurer has denied or terminated your disability insurance claim, contact us for assistance.