The case of Gina Pike v. Hartford Life and Accident Insurance Company (Hartford) is an example of how hard insurance companies work to deny or terminate claimants’ long term disability (LTD) benefits. Pike received LTD benefits for eight years. Two of those years for which Pike received benefits were for when Hartford agreed she was unable to work in her own occupation.

After two years, the definition of disability changed to requiring Pike to be disabled from any job for which she was educated and qualified (she has a Bachelor of Science in microbiology). The job also had to meet certain earnings standard as defined by the policy. For six years, Hartford agreed she was disabled from working in any occupation.

Then, following a review of medical records by professionals hired by Hartford, Hartford terminated her benefits. After filing two administrative appeals, she was still denied benefits, so Pike filed an ERISA lawsuit.

The U.S. District Court for the Eastern District of Texas agreed with Pike and ordered Hartford to continue paying her LTD benefitsfrom the December 14, 2016, termination date as well as prejudgment interest. The Court also ordered Hartford to pay attorneys’ fees and costs.

The District Court adopted the recommendations of the Magistrate Judge who concluded that “Plaintiff has demonstrated by a preponderance of the evidence that she cannot perform the essential duties, which includes the ability to work a full work week, of any occupation for which she qualifies. Plaintiff has shown by a preponderance of the evidence that her disability persisted beyond December 14, 2016.”

Summary of Facts

Pike suffered from severe back pain which began in 2002. She was diagnosed with lumbar degenerative disc disease with lumbar radiculopathy. She had multiple surgeries to repair the severe pathology in her lumbar and sacral vertebrae. At one point, surgery was done to remove hardware that had been previously used in an attempt to stabilize her back. On April 24, 2008, she first began receiving LTD benefits from Hartford.

In notes to the administrative file made by Hartford in April 2010 and again in February 2011, Hartford stated that due to Pike’s multiple back surgeries and continued treatment for chronic pain, she would be unable to “sustain full-time work.” From November 2010 to July 2015, Pike routinely updated Hartford about her treatment, her pain, and her pain management issues.

Despite medical verification that Pike could not work in any occupation, Hartford essentially said, “so what?” The company informed Pike by letter that her LTD benefits would be terminated effective December 15, 2016. She was no longer considered disabled under the terms of her insurance policy.

Pike aggressively administratively appealed the denial, but Hartford remained firm. The record contained reams of reports by treating physicians, particularly medical records from a certified pain management specialist Dr. Gajraj, who treated Pike for more than five years.

Gajraj reported on June 6, 2017, that Pike suffered from chronic pain and could not sit or stand for any length of time, and had cognitive issues due to large doses of pain medication she required for pain management. Hartford was not satisfied with this report and upheld its termination of her benefits, so she filed this ERISA lawsuit.

The Magistrate Judge conducted a comprehensive de novo review of the case and, in a 60-page Report and Recommendations, found in favor of Pike. Hartford objected to many aspects of the R&R. Although Hartford acknowledged de novo review was appropriate, it argued that the Magistrate Judge exceeded the scope of that review.

District Court Agrees with Magistrate Judge and Explains the Scope of de novo review

Hartford claimed that de novo review “requires that the court apply the same standard as the plan administrator in deciding whether benefits were owed under the plan’s terms.”

Pike argued that de novo review “requires the court to independently weigh the facts and opinions in the administrative record to determine whether the claimant has met her burden of showing she is disabled within the meaning of the policy…what happened before the plan administrator is irrelevant.”

Since no Fifth Circuit cases could be found (the circuit which reviews cases from Texas) that directly decided this issue, the Pike Court found it appropriate to consider cases from other circuits. In looking at cases from the First, Sixth, Ninth, Tenth, and Eleventh Circuit Courts of Appeals, the Court found all of them consistently found that “[u]nder the de novo standard of review, the Court’s task ‘is to determine whether the administrator made a correct decision.’”

The Court then proceeded to exercise de novo review of the Magistrate Judge’s R&R, keeping in mind that she “evaluated the persuasiveness of each side’s case to determine if Plaintiff has adequately established that she is disabled under the policy.”

In its 26-page review and final order, the Court agreed with the Magistrate Judge’s opinion on every issue presented by Hartford and found in favor of Pike. The District Court agreed the Magistrate Judge had applied the proper standard of review, and Pike proved her case by a preponderance of the evidence.

Consistent with the Magistrate Judge’s recommendations, the District Court ordered LTD benefits should continue from December 16, 2016, on, with prejudgment interest. Attorneys’ fees and costs were also ordered.

This case was not handled by our firm, but at Dell & Schaefer, we handle ERISA administrative appeals and lawsuits all over the nation. Although there are no guarantees in the law, we have a track record of success. No matter where you are at in your claim process, feel free to contact one of our disability attorneys for a free consultation.