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What happens when an anticipated medical improvement never happens?

That question was answered in a recently reported federal court ruling from Michigan, Sun v. United of Omaha Life Ins. Co., 2017 WL 3050477 (E.D. Mich. July 19, 2017).  The case involved Julia Sun, who worked as a registered nurse caring for quadriplegic patients. After she injured her foot in 2010, and because she also suffered from lupus, Sun qualified both for long-term disability benefits as well as for Social Security disability insurance benefits.  However, in February 2013, despite prior findings that there were no occupations Sun could perform that met the policy's wage requirements, United terminated her benefits.  The court overturned that decision.

After reviewing the medical evidence, the court observed that the treating doctors determined that Sun was unable to perform sedentary or light work on a sustained basis, and United's reviewing doctors agreed.  However, Sun Life based its conclusion on the finding of a vocational consultant.  Consequently, the court found: 

The administrative record does not support United's findings that Sun can perform sedentary work and is not disabled. United ignores findings from Sun's treating physicians that show Sun is disabled, and instead "cherry-picks" the opinion of Jellenik--a non-examining, vocational consultant--to find evidence that supports a conclusion in their favor. See Spangler v. Lockhead Martin Energy Systems, Inc., 313 F.3d 356, 362 (6th Cir. 2002) (finding the defendant's decision to terminate LTD benefits "arbitrary and capricious" where it ignored unfavorable medical evidence and relied on "cherry-picked" evidence that was favorable). 

The court then added: 

Although United is not required to give treating doctors' findings deferential weight, United must give them due consideration and have good reasons to reject their opinions. Elliot v. Metro. Life. Ins. Co., 473 F.3d 613, 620-21 (6th Cir. 2006). While United did mention parts of Dr. Benenati's and Dr. Sulich's evaluations, they failed to provide good reasons for adopting a non-examining vocational consultant's opinion over Sun's treating physicians. 

United tried to rationalize its decision by pointing to "an expectation or goal of improvement;" however, such improvement was never achieved. Hence, the court concluded that reliance on "aspirational language" is not a justification for reaching a conclusion that differed from the existing medical findings.  The court further explained: 

United based its conclusions on aspirational language in medical reports, Sun's goals, and medical consultants who did not treat or examine Sun, despite ample evidence of disability based on examinations and findings. This leads this Court to conclude that United's decision to terminate Sun's LTD benefits was arbitrary and capricious. See Spangler, 313 F.3d at 362; Evans v. Unumprovident Corp., 434 F.3d 866, 877 (6th Cir. 2006) ("[A] plan administrator may not arbitrarily disregard reliable medical evidence proffered by a claimant, including the opinions of a treating physician."). 

Consequently, the court awarded reinstatement of benefits, along with a potential recovery of fees, costs, and interest, although the court also determined that the award would be offset by Social Security payments. 

Surprisingly, the court did not cite McDonald v. Western-Southern Life Insur.Co., 347 F.3d 161 (6th Cir. 2003), which held that an expectation or goal of improvement was not a sufficient basis to conclude that the claimant was not presently disabled.  However, the court still came to the same conclusion and rendered two important findings in this ruling - First, that opinions based on cherry-picking the record cannot sustain an adverse finding.  Second, that "aspirational language in medical reports" cannot suffice as the basis for terminating benefits. 

 

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DeBofsky, Sherman & Casciari, PC