&uot Erisa and Disability Benefits Law Blog: Plan's Denial of ERISA Benefits Upheld
09 | 19 | 2006 Posted By John Wood
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Plan's Denial of ERISA Benefits Upheld

Myrtle McGee worked as a restaurant general manager.  She received short-term and long-term disability benefits under her employer’s ERISA plan.  The long-term disability portion of the plan paid benefits during the first 24 months under an “own occ” standard and afterwards under an “any occ” standard.  The plan also limited benefits to 24 months for disabilities caused or contributed to by a mental or nervous condition.

 

Near the end of the 24-month benefit period, the claims administrator, VPA, Inc.,  hired an outside physician to perform an evaluation of McGee.  The physician apparently concluded that McGee was able to perform sedentary work.  VPA also obtained a “Functional Capacity Evaluation” and an “Employability Assessment” that supported VPA's position that McGee was capable of performing sedentary work.

 

Based on these opinions, VPA terminated McGee’s benefits, stating that after the initial 24-month period she would no longer meet the plan’s definition of “totally disabled.”  VPA denied McGee’s internal appeal, and she filed suit in federal court.

 

Applying the arbitrary and capricious standard of review, the federal district court ruled in favor of the plan.  The court analyzed the case as follows: 

VPA obtained three separate evaluations: the IME performed by Dr. Changaris; the Functional Capacity Evaluation performed by Healthsouth, and the Employability Assessment performed by CorVel.  The IME concluded that Plaintiff was incapable of light duty, but it did not rule out occupations requiring only the sedentary physical demand level.  The Functional Capacity Evaluation concluded that Plaintiff was capable of performing occupations requiring a sedentary physical demand level, and the limitations it found were consistent with those recommended by the IME.  Finally, the Employability Assessment concluded that Plaintiff could find jobs with low physical demands.  These evaluations strongly support VPA's decision to terminate benefits under the Plan's specific guidelines.  Plaintiff does not argue that this Court should ignore or completely discount these evaluations due to any independent circumstances.

 

Plaintiff's only submission in support of her claim for continued benefits was a letter from her treating physician dated January 26, 2005 stating his belief “that the patient is totally disabled.”  However, her treating physician provided no explanation whatsoever for the opinion that she was totally disabled and his opinion is not stated to a reasonable degree of certainty within the medical profession.  Plaintiff does not make a persuasive argument that this brief letter overcomes the weight of Defendant's evidence supporting its decision to deny benefits.

The cite is McGee v. YUM!Brands, Inc., 2006 WL 2631976 (W.D. Ky. Sep. 12, 2006).

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