Gina Pike received long term disability (LTD) benefits for eight years from her disability insurer, Hartford Life and Accident Insurance Company (Hartford) when the company suddenly terminated her benefits. She filed two administrative appeals, but Hartford still denied benefits, so Pike filed this ERISA lawsuit.
In Gina Pike v. Hartford Life Insurance Company, a U.S. District Court for the Eastern District of Texas decided in favor of Pike and ordered Hartford to reinstate her LTD benefits effective December 16, 2016, the day after Hartford had terminated them. Initially, the case was reviewed by a Magistrate Judge who sent a 60-page Report and Recommendations to the Court. The R&R concluded that Pike had proved by a preponderance of the evidence that she was entitled to LTD benefits from the date of termination forward.
Hartford filed objections to the R&R with the District Court. The Court reviewed the objections and, in a 26-page single-spaced opinion, concluded the Magistrate Judge was correct and that according the terms of its disability insurance policy, Hartford must pay Pike LTD benefits from the date of its termination on December 16, 2016. The Court also ordered Hartford to pay prejudgment interest and attorneys’ fees and costs.
Brief Summary of Facts
Gina Pike began having back problems in 2002. She was diagnosed with lumbar degenerative disc disease and lumbar radiculopathy. She had several back operations, including one operation to remove metal that had been inserted in a previous operation with the hope that it would stabilize her vertebrae.
All of her treating physicians including her surgeon, and particularly her pain specialists reported that she could not sit or stand long enough to be employed. She often had to rest in bed. Plus, she was taking pain medications that caused her cognitive problems.
Hartford began paying Pike LTD benefits on April 24, 2008, when it determined she was disabled from working in her own occupation. Two years later, Hartford determined she was disabled from working in any occupation for which she was educated (she has a Bachelor of Science in microbiology) or qualified. Pike periodically updated her medical records with Hartford and Hartford continued paying benefits.
In December 2016, after having Pike’s medical records reviewed by one of its own paid medical professionals, and an independent medical exam performed by another one, both of whom opined she could work, Hartford terminated benefits.
District Court Agreed with the R&R that Relied on Medical Records and Opinions of Treating Physicians in Determining Pike Was Entitled to Have Her LTD Benefits Reinstated
Hartford argued that the Magistrate Judge erroneously relied on outdated medical records, and gave more weight to treating physicians than Hartford’s reviewing physicians. The District Court agreed with the R&R from the Magistrate Judge and held that Hartford was wrong on both issues.
The Court found that the complete medical records and statements of treating physicians proved by a preponderance of the evidence that Pike was disabled. For example:
- In 2008, the neurosurgeon who operated on Pike stated that Pike could not sit or stand or walk for more than two hours a day. He also stated “these limitations are permanent.
- Hartford made a note to the file on February 20, 2011, that said “due to chronic intractable pain she is limited to 15-20 minutes sit/stand/walk for no more than 4/hrs/day. Therefore, it is reasonable that [Plaintiff] would be unable to sustain fulltime any occ[upation] activities.”
- On July 20, 2015, Dr. Gajraj, Board Certified in Pain Management, who had treated Pike for more than five years, sent Hartford his opinion that Pike “could walk, stand, and sit for fifteen to twenty minutes at a time and for no longer than four hours per day.”
- The Court gave little weight to the opinion of Dr. Sklar, Hartford’s physician who performed an independent medical exam (IME) and opined that Pike could work. Sklar had quite a bit of the information from the medical record wrong, including important surgical dates and the types of surgeries that were performed.
- In her administrative appeal, Pike submitted a letter from Dr. Gajraj stating that in addition to suffering chronic back pain, she could perform work for no more than 2-4 hours a day. Plus, she was taking prescription medicine that “can impact cognition and the ability to perform detailed task.”
Additionally, the Court found that there was no evidence of improvement since Hartford “previously found Plaintiff was unable to sustain full time work in any occupation.” The Court relied on precedent which specifically states that “unless information available to an insurer alters in some significant way, the previous payment of benefits is a circumstance that must weigh against the propriety of an insurer’s decision to discontinue these payments.”
Taking all of these things into consideration, and because de novo review did not require the District Court to give deference to the plan administrator’s decision, the Court agreed with the R&R and ordered benefits to be paid effective on the previous termination date of December 16, 2016, with prejudgment interest. The Court ordered Hartford to pay attorneys’ fees and costs, the amounts to be determined later after further briefing by each party.
This case was not handled by our firm, but our attorneys at Dell & Schaefer represent clients nationwide as they fight for the LTD benefits to which they are entitled. Call any of our disability attorneys for a free consultation.