How Roberts Disability Law Successfully Appealed Guardian’s Termination of Long-Term Disability Benefits for Client With Significant Impairment Affecting the Ability to Perform Any Gainful Occupation

The Client’s Long-Term Disability (LTD) Claim

Our client, “Tom,” was employed as a Medical Laboratory Scientist when he became disabled as a result of cervicalgia, cervical radiculopathy, carpal tunnel syndrome, bilateral occipital neuralgia, intractable migraines, and associated bilateral hand pain and chronic neck pain. As a result of his symptoms, Tom was restricted from prolonged flexion of the cervical spine, repetitive forceful gripping or grasping, and pushing or pulling greater than 25 pounds—all activities which were necessary for his occupation, which involved using his hands and neck for “pipetting” lab samples. Disability insurer, Guardian Life Insurance Company of America, approved and paid benefits for two years, but then terminated benefits concluding that Tom was no longer eligible for benefits because he did not meet the definition of disability. After 24 months, Tom had to prove he was disabled from “any occupation” rather than from his “own occupation.”

In reaching that conclusion, Guardian cherry-picked the evidence and restricted its review of the medical records and treatment with an eye toward developing a basis for termination. In fact, Guardian’s termination letter cited the wrong policy language and standard for determining disability, thus calling into question the accuracy of its claim analysis. In terminating benefits, Guardian pointed to an “Objective Medical Evidence” requirement, which was not contained in his employer’s policy. Guardian also reached its decision without having Tom’s claim reviewed by any physician, much less a specialist in neurology and/or pain management. Guardian failed to acknowledge the statements of Tom’s treating physicians who said that he cannot sit, stand, or walk for more than 2 hours; cannot lift/carry/push/pull more than 5 pounds; and can do no firm grasping, fine manipulation or push/pull arm controls. Guardian also ignored the report of a Qualified Medical Examiner, who acknowledged Tom’s inability to sit for any length of time, even though it accepted other opinions contained in the QME report. Instead, Guardian provided its in-house vocational personnel with incomplete restrictions and limitations and, not surprisingly, identified several occupations it concluded that Tom could perform – occupations that require use of his neck and hands. Based on its identification of alternate occupations it decided Tom could perform, Guardian terminated benefits.

Our Strategy on Tom’s ERISA Appeal

Our team, led by Kristin Kyle, outlined an appeal plan focusing on the already existing objective support for Tom’s disability, supplemented by additional objective testing, vocational analysis, and detailed physician support for ongoing disability. On appeal, our team compiled the following: (1) updated treatment records and diagnostic testing, in particular brain and cervical MRIs documenting an arachnoid cyst which was contributing to the intractable migraines, cervical changes, and arthropathy; (2) additional objective testing demonstrating ongoing functional incapacity; (3) three treating physician statements supporting ongoing disability; and (4) many statements of disability prepared by Tom’s primary physician and specialists outlining the nature and extent of his functionally impairing symptoms; and (5) several detailed declarations of Tom, family members, and coworkers offering specific examples and context as to how his medical conditions preclude full-time work in any occupation. Functional testing objectively confirmed what our client’s doctors had been certifying all along, that Tom remained unable to perform any occupation due to his significant restrictions and limitations. An independent medical examination by a board-certified neurologist agreed with each of Tom’s treating providers. Finally, a vocational assessment outlined not only how Tom’s restrictions and limitations precluded him from performing any of the occupations Guardian had identified, but that the salaries for those occupations did not meet the gainful wage threshold.

Outcome

As a result of our detailed attention to each aspect of Guardian’s denial and assembling both objective and subjective evidence to support Tom’s ongoing restrictions and limitations, Guardian was forced to reinstate ongoing total disability benefits. We continue to represent Tom in his ongoing claim with Guardian to ensure that Guardian continues to pay him as long as he remains disabled.