Green v. Prudential Insurance Company of America
Green v. Prudential Insurance Company of America
383 F. Supp.2d 980, 990-91 (M. D. Tenn.2005)
Our client applied for long term disability benefits from Prudential Insurance Company of America after fibromyalgia forced her to leave her job at a bank. Prudential initially denied her benefits, and she appealed. After her benefits were denied for a second time, we moved to suit.
The court uses the arbitrary and capricious standard of review if a long term disability plan gives the administrator, or fiduciary, discretionary authority to determine the eligibility for benefits. (Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 115, 109 S.Ct. 948, 103 L.Ed.2d 80 (1989.) The court found that the language in Prudential’s plan was sufficient to grant discretionary authority to the plan. Thus, the arbitrary and capricious standard was applied.
The court must consider if there is a conflict of interest in an administrator’s decision to deny a claimant benefits. The 6th Circuit holds that if a claims administrator funds and administers its plan, it faces a direct cost when benefits are granted while also directly profiting from the rejection or cessation of benefits. (Killian v. Healthsource Provident Adm’rs, Inc., 152 F.3d 514, 521 (6th Cir.1998.)) The court considered this when determining if Prudential acted arbitrarily and capriciously.
When Prudential denied our client’s request, it recognized her fibromyalgia diagnosis from her treating physician. However, Prudential argued that fibromyalgia is not necessarily indicative of a “totally disabling condition.” The 6th Circuit holds that fibromyalgia can be disabling. (Preston v. Sec’y of Health & Human Servs., 854 F.2d 815, 818 (6th Cir.1988.))
We argued that Prudential improperly required objective findings before reviewing our client’s request for benefits as this requirement is not in her plan. The court, pursuant to ERISA, determined it unreasonable to require objective findings before awarding benefits to a claimant.
Prudential argued that our client’s medical records and opinions from her treating physicians were not sufficient evidence to prove she was disabled under its plan. The court found that Prudential was unreasonable in denying our client’s benefits based upon this evidence. Pursuant to ERISA, plan administrators cannot arbitrarily refuse to credit reliable evidence, including the opinions of a treating physician. Prudential arbitrarily refused to credit, and attached little to no significance to, evidence which the court found reliable.
Physicians hired by Prudential made their conclusions without the benefit of reviewing the results of an independent psychiatrist examination, something that both physicians recommended. The court found that it was unreasonable for Prudential to not require an independent psychiatric evaluation of our client given her fibromyalgia diagnosis.
The court found Prudential’s letters denying our client’s benefits to be unclear. Prudential did not follow its experts’ advice concerning an independent psychiatric evaluation, did not conduct an independent physical examination to assess our client’s capacity to work, did not defer to her treating physicians, and did not defer to her personal account of her limitations. Considering these factors, the court determined that it was unclear what evidence Prudential used when denying our client’s benefits.
The court found that Prudential arbitrarily and capriciously denied our client’s claim, and did not provide a “reasoned explanation, based on evidence” for denying these benefits. The matter was remanded to Prudential to reevaluate our client’s claim.
