In Berg v. The Lincoln National Life Insurance Company, No. 2:24-CV-00097-SAB, 2025 WL 252481 (E.D. Wash. Jan. 21, 2025), Washington Eastern District Judge Stanley A. Bastian granted judgment to Plaintiff Barbara Berg, a former Walmart employee, against The Lincoln National Life Insurance Company (“Lincoln”). In reviewing Lincoln’s denial of Berg’s long-term disability (LTD) benefits under her Group Disability Income Policy, the Court found that Lincoln’s decision to terminate benefits after two years was arbitrary and capricious. This decision highlights critical aspects of ERISA litigation, particularly regarding the standards for reviewing benefit determinations and the weight given to evidence from treating physicians and governmental agencies like the Social Security Administration (SSA).
Berg worked at Walmart as a team lead until she became disabled due to several debilitating conditions affecting her right hand and forearm. Her ailments included De Quervain’s tenosynovitis, complex regional pain syndrome, and degenerative disc disease, leading to significant functional limitations. After initially approving and paying LTD benefits beginning in 2021, Lincoln terminated benefits two years later at the change in disability definition, following reviews by retained physicians who concluded that Berg could return to work full-time, albeit with some restrictions.
Berg contested this decision, arguing that Lincoln failed to provide a fair review of her disability claim. She supported her appeal with evidence from her treating physician, Dr. Barry Bacon, who detailed her permanent disability and functional limitations. Additionally, she submitted an SSA ruling that also declared Berg permanently disabled and which found no jobs in the national economy that she could perform given her condition.
The court conducted a de novo review of Berg’s claim, a standard in ERISA cases that requires the court to examine the administrative record without deferring to the plan administrator’s prior decision. This approach underscores ERISA’s mandate that benefit plans be administered in a manner that ensures participants receive a full and fair review of their claims. A pivotal element of the court’s analysis was its consideration of the medical opinions on record. The court gave substantial weight to the opinions and conclusions of Berg’s treating physician, Dr. Bacon, who had consistently documented her severe limitations and permanent disability status. Dr. Bacon’s evaluations were supported by a thorough review of Berg’s medical history and direct examinations, lending significant credibility to his conclusions. The Ninth Circuit has previously emphasized the importance of treating physician opinions, particularly when they are well-supported by medical evidence, as in Berg’s case.
The court was also influenced by the SSA’s determination, which found Berg to be disabled under its standards. While SSA rulings are not binding on private insurers, the court noted that Lincoln’s failure to align its decision with the SSA’s assessment raised questions about the integrity of its review process. The court highlighted that Lincoln did not adequately address why it diverged from the SSA’s findings, which suggested that Berg’s impairments were consistent and supported by the longitudinal medical evidence.
Lincoln’s reliance on the opinions of its own medical reviewers who did not examine Berg personally was another concern for the court. Although ERISA does not require insurers to conduct independent medical examinations, the court found it troubling that none of Lincoln’s experts reviewed the entirety of Berg’s evidence, particularly the detailed assessments from her treating physician, Dr. Bacon. This lack of comprehensive analysis further undermined the credibility of Lincoln’s decision.
Moreover, the court criticized Lincoln for not providing a clear explanation of the evidence needed to perfect Berg’s claim, as required by ERISA regulations. The insurer’s decision letter lacked sufficient detail about why the presented evidence was deemed inadequate, demonstrated a failure to engage meaningfully with regard to the medical assessments, and failed to address the SSA’s findings.
Ultimately, the court concluded that Berg met the policy’s definition of “disabled,” which required proof of an inability to perform any occupation due to her medical conditions. The court’s decision to award retroactive LTD benefits to Berg reflects the judicial system’s role in correcting arbitrary denials of benefits by insurers and ensuring that claimants receive the protections intended under ERISA.
This case serves as a critical reminder of the rigorous standards insurers must meet when denying disability benefits and the substantial weight courts may place on comprehensive medical evidence and governmental disability determinations. It underscores the necessity for insurers to conduct thorough, unbiased reviews and to provide clear, well-reasoned explanations when denying benefits claims.
If Lincoln or your insurer has denied or otherwise limited your disability insurance claim, contact us for assistance.
*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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