Legal Summary: Potter v. Liberty Life Assurance Company of Boston
Potter v. Liberty Life Assurance Company of Boston
132 Fed.Appx. 253 (11th Cir. 2005)
Our client had to stop working as a senior claims underwriter at AFLAC due to several medical conditions. Potter v. Liberty Life Assur. Co. of Boston, 132 Fed.Appx. 253, 254 (11th Cir. 2005). Dr. Martin, her primary care physician, diagnosed her with several disabling conditions. Id. Our client first took medical leave from AFLAC on October 8, 1999, and her claim for long-term disability benefits was received by Liberty on February 3, 2000. Id. In the claim application, Dr. Martin stated that our client should be restricted to a daily maximum of four hours of clerical work and have limited exposure to stress and interpersonal relations. Id.
Since Liberty claims manager, Ms. Cancer, had no medical training, she relied on a nurse file reviewer to evaluate our client’s claim. Id. On March 15, 2000, the nurse was still waiting for additional office notes from another of our client’s physicians, Dr. Fox, and the nurse mailed Dr. Martin a questionnaire asking for the basis on which she had diagnosed our client with one of her conditions; the nurse also asked whether Dr. Martin would recommend a psychiatric evaluation and requested Dr. Martin to respond by March 24, 2000. Id. at 255.
Also on March 15, 2000, Ms. Cancer denied our client’s claim based on outdated office notes from Dr. Fox and later gave no explanation for denying the claim before the nurse’s review was complete. Id. at 255. Despite Ms. Cancer’s denial of the claim, the nurse reviewer continued her investigation and received additional information from Dr. Martin and Dr. Fox, including more details from Dr. Fox supporting his opinion. Id.
On May 16, 2000, our client wrote a letter to Liberty to appeal the denial of her claim, and this letter was reviewed by Ms. Malia, an appeal review consultant working as a contractor for Liberty. Id. Ms. Malia denied the appeal, relying on Dr. Martin’s recommendation that our client was capable of four hours of sedentary activity daily. Id. at 255, 256. Ms. Malia did not answer the question of how the mental limitations placed by Dr. Martin on our client would affect her ability to work; instead she stated, “I would refer that question to a doctor.” Id. at 256. However, neither Ms. Malia nor any other Liberty agent referred our client’s case to a doctor for evaluation. Id. Additionally, Liberty did not employ any vocational expert or consultant to evaluate the demands of our client’s job as they related to the physical and mental restrictions assessed by Dr. Martin. Id.
When our client obtained disability benefits from the Social Security Administration, the administrative law judge found she was “unable to sustain even this limited [part-time] amount of sedentary work.” Id. Liberty, informed of the favorable Social Security decision, declined to take into account that our client had received disability benefits from the SSA and denied her appeal again. Id.
We then sued Liberty on behalf of our client under ERISA, and the court of appeals ultimately agreed with us that it was arbitrary and capricious to deny benefits because analysis was never done to determine whether our client’s actual occupational duties were sufficiently sedentary, or whether the stress level and degree of interpersonal interactions were too demanding, in contravention of Dr. Martin’s recommendations. Id. at 259.
The court also noted Liberty erroneously found our client was not disabled because they claimed she could do four hours of sedentary work per day. The court noted this was contrary to our client’s own testimony, was not consistent with her other limitations, and was contrary to the Social Security Administration’s finding that she was totally disabled. Id.
The court further explained that Liberty erroneously asserted that,
Dr. Martin concluded that [our client] could perform “her sedentary occupation” on a part-time basis. This is incorrect; Dr. Martin never concluded [our client’s] occupation was sedentary, or that she could work on a part-time basis. Dr. Martin merely said [our client] could perform four hours of sedentary activity with mental limitations restricting her to limited stress and interpersonal relations. Dr. Martin never determined whether [our client’s] actual occupational duties were sufficiently sedentary, or whether the stress level and degree of interpersonal interactions were too demanding. Liberty did not conduct this analysis either.
Id.
Further, Liberty’s claims handler acknowledged that whether our client could perform the work with her cognitive limitations would require the review of a doctor, but Liberty did not conduct that analysis.
The court also found that Liberty failed to conduct a full analysis of the evidence, failed to consult with a vocational expert to assess our client’s her ability to work in light of her restrictions, and failed to follow through on further evaluations Liberty’s own nurse recommended.
The court also noted that Liberty failed to show that its decision to deny our client’s claim was not motivated by self-interest. Id. at 260. The court of appeals reversed the district court’s grant of summary judgment for Liberty and remanded the case to Liberty for a proper decision. Id.
