Combe v. Life Ins.Co. of North America

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Combe v. Life Ins.Co. of North America, 2007 U.S.Dist.LEXIS 45187 (E.D.La. 6/21/2007)( Issue: Full and Fair Review, Combination of Impairments) .  The plaintiff, who had worked as the law librarian and served as a tenured faculty member of the Tulane Law School, had to cease working due to cardiac cardiomyopathy and ventricular tachycardia for which he had a defibrillator implanted.  Although Combe’s treating physicians unequivocally supported the plaintiff’s application for benefits, LINA denied the claim, and Combe appealed.  However, LINA neither acknowledged the appeal nor did it render a decision within 90 days of the June 26, 2006 appeal submission.  The appeal was finally acknowledged on September 14, 2006, after repeated requests by Combe’s counsel; and on September 29, 2006, the prior decision was upheld.  Combe immediately filed suit, and the matter was before the court on cross-motions for summary judgment.

Applying Fifth Circuit precedent, the court was required to grant deference to LINA’s findings.  However, the court ruled:

Given the myriad of failures to comply with the applicable regulations and the absence of factual support in the record for its denial of Combe's application for LTD benefits, see discussion  infra, CIGNA is entitled to a bare minimum of deference in the Court's determination of whether it abused its discretion in this matter. *13.

The court found multiple defects in LINA’s analysis.  The court expressed its dissatisfaction with LINA’s failure to consider Combe’s occupational duties and its disregard of all of the plaintiff’s medical conditions.  The court also pointed out there was no mention in the record that LINA even reviewed the plaintiff’s occupational duties or that “any administrator at CIGNA gave a thought to the actual duties, the intellectual demands or the physical endurance, required by Combe's occupation, although evidence of those demands was readily apparent in the Administrative Record.” *24.  The court added (with a dose of sarcasm):

There is evidence in the Administrative Record of Combe's physical and psychiatric medical conditions including sleep apnea, daytime sleepiness and chronic fatigue, attention deficit disorder, lack of motivation and focus, major depression and serious heart problems exacerbated by stress. Apparently, in CIGNA'a view, as long as Combe's job duties did not require him to operate heavy equipment, work on an off-shore oil platform, drive a vehicle or physically endanger others, it should be perfectly acceptable for him to sleep on the job, or when awake, to be fatigued, unable to read and comprehend a short legal article, unable to focus on an issue, and unable to interact with or supervise others during his normal work day. *24-*25.

Consequently, the court determined that LINA failed to comply with the policy by considering the plaintiff’s occupation. The court further held the insurer abused its discretion by doing so.  Without the production of any internal guidelines or procedures, the court could not review the defendant’s consistency in its interpretation or evaluate whether the insurer acted in accordance with the plan’s provisions.  Following  Robinson v. Aetna, 443 F.3d 389 (5th Cir. 2006), the court found that procedural violations of the ERISA claim regulations demonstrate a failure to provide a full and fair review.  The court then cited LINA’s utter failure to even acknowledge Combe’s appeal within 45 days of the appellate submission, as the regulations require.  Moreover, the court disapproved of the insurer’s initial nurse case manager review and of the review conducted by LINA’s medical directors whose areas of expertise were undisclosed.  It was also evident to the court that LINA engaged in a selective review of the record, crediting only a portion of the treating physicians’ findings to support a denial while utterly rejecting the findings supporting disability.  The court detailed the medical evidence and pointed to specific areas that LINA completely disregarded such as the severe sleep apnea that had been diagnosed.  The court also was critical of LINA’s reviewing psychiatrist, Dr. Unsell, who ignored the treating psychiatrist’s diagnosis of major depression simply because there were no neuropsychological test results, even though the doctor’s clinical observations over the course of years of treatment were consistent with the doctor’s diagnosis and functional evaluation.  This led to the following conclusion:

In this case, CIGNA repeatedly selected a specific test result or individual comment from each of the treating physicians' office notes to support its denial of Combe's claim, but ignored the bulk of the information that was available in the Administrative Record from these same physicians. It disregarded their uncontroverted opinions and declarations that each considered Combe to be disabled by his multiple medical conditions. The administrator appears to have been inappropriately preoccupied with identifying a precise symptomology or etiology to support a finding of disability as of a particular date and from a specific, individual physical or psychiatric condition. *46

The court further determined that LINA improperly evaluated each medical condition in isolation:

CIGNA persisted in evaluating each individual medical or psychiatric condition as a separate issue from every other condition, and never considered the combined effect of all of Combe's combined medical and psychiatric conditions on his ability to continue to perform the material tasks of his regular occupation. Rather than putting the pieces of a puzzle together, CIGNA examined each piece individually, and finding it insufficient to support a finding of disability, put that piece aside and proceeded to examine the next piece, again finding that piece lacking. The administrator then complained that it could not "understand" the whole picture that is the completed puzzle. *48.

Despite every doctor’s conclusion that the combination of all of Combe’s impairments is what caused him to be disabled, LINA gave no consideration whatsoever to those findings, which led the court to its ultimate conclusion that “CIGNA's handling of Combe's claim was perfunctory and superficial, and not in good faith.” *49.  Based on the evidence presented, the court then thoroughly rejected LINA’s claim that the record revealed genuine issues of material fact.   On the contrary, the court found the record unquestionably led to the conclusion that Combe was disabled due to a combination of three medical conditions – heart disease, sleep apnea, and major depression.  Moreover, because the physical impairments exacerbated the depression, the court deemed the disability “physical.”  Hence, the court ordered benefits payable from onset through the maximum benefit period with interest as well as mandatory contributions to the Tulane University Pension Plan.  The court also awarded fees, with the amount to be determined following the submission of the plaintiff’s application for fees.

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