District Court Finds That Lincoln National Did Not Abuse Its Discretion in Concluding That Treating Provider’s Changed Opinion on Disability Was Not Supported by The Medical Evidence

In Drake v. Lincoln Nat’l Corp., et al., No. CV-22-08230-PCT-SPL, 2024 WL 2942695 (D. Ariz. June 11, 2024), Arizona District Judge Steve P. Logan granted judgment in favor of Defendant Lincoln National, concluding that it did not abuse its discretion in terminating ERISA governed long-term disability (“LTD”) benefits after Plaintiff’s treating provider approved her return to work and later changed his opinion without any supporting medical evidence.

Plaintiff, who was employed as a registered nurse for Yavapai Regional Medical Center, stopped working in August 2020 due to a foot injury for which she underwent outpatient surgery. Lincoln approved Plaintiff’s LTD claim and paid benefits while she recovered. In February 2021, Plaintiff’s surgeon opined that Plaintiff had “recovered well” and she “may return to work.” The surgeon did, however, note that Plaintiff still had an underlying foot deformity that may cause some pain and disability, but that from a surgery standpoint, her torn tendons had healed. Lincoln terminated benefits noting no information to support ongoing functional impairment due to the deformity, particularly given that she had worked with the deformity prior to her foot injury. In March 2021, after the denial, Plaintiff provided a different opinion from her surgeon, who now opined in a letter that Plaintiff continued to have significant pain and disability and was unable to walk for more than a few minutes at a time due to her underlying cavus foot deformity. He noted previous discussions of reconstructive surgery but asserted that this was a recommendation of last resort. He opined that Plaintiff was unable to work due to the significant pain from her foot deformity. Plaintiff’s physician, however, did not supplement the letter with any medical records reflecting updated diagnosis and/or treatment. Nor did the physician provide any specific restriction and limitations. Lincoln upheld its decision on appeal. The instant action ensued.

Addressing Plaintiff’s Motion for Judgment, the Court first held that the abuse of discretion standard of review was appropriate in this case. The Court found that the LTD Policy afforded Lincoln discretion, and that while a structural conflict of interest existed because Lincoln was both responsible for determining eligibility and paying benefit, it had taken active steps to reduce potential bias and to promote accuracy. As such, the Court reviewed Lincoln’s conduct with only a moderate amount of skepticism.

With regard to the merits, the Court found that Plaintiff’s alleged procedural errors did not arise to the level of an abuse of discretion. The evidence demonstrated that Plaintiff’s treating provider approved her return to work, and later changed his opinion without any supporting medical records only after Plaintiff’s benefits were terminated. The Court found, contrary to Plaintiff’s argument, that Lincoln had provided specific reasons for denying Plaintiff’s claim and had properly advised what materials Plaintiff would need to provide on appeal. Contrary to Plaintiff’s assertion, the Court found that Lincoln had fully considered the treating provider’s changed opinion, which was opposite of both his prior opinion and the opinion of Lincoln’s medical reviewer opinion. Further Lincoln did not fail to consider other medical impairments as those other conditions did not exist prior to when the policy ended, and Plaintiff was no longer actively at work. Finally, the Court found that Plaintiff could not pursue penalties for Lincoln’s alleged delay in providing the claim file as it is not a plan document within the meaning of ERISA’s penalty provisions.

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