In Cooper v. Life Ins. Co. of North America, the U.S. Court of Appeals for the Sixth Circuit established precedent for those whose case arises in Kentucky, Michigan, Ohio or Tennessee. After the Plan’s denial of long term disability benefits to the complainant, that was upheld through two administrative appeals and by a Tennessee federal district court, the Sixth Circuit reversed. The court refused to remand the case to the plan administrator for further evaluation since it concluded “that Cooper has clearly established that she is disabled under the Plan.”

Initial Denial of Benefits and First Appeal

Becky Cooper injured her back while she was on a work-related business trip. A medical evaluation revealed she suffered from degenerative disc disease and spondylolisthesis and performed a partial laminectomy. The Life Ins. Co. of North America (LINA) awarded her short term disability benefits during her recovery, which took longer than was expected.

Initial denial of benefits: When the short term benefits expired, Cooper applied for long term disability benefits. Her request was denied when she failed to provide LINA the information it asked for. Based on that act, the Sixth Circuit held that the initial denial of benefits was not arbitrary and capricious.

First administrative appeal: When her benefits were denied, Cooper filed an administrative appeal. She submitted additional medical information in an attempt to satisfy the demands of LINA. LINA hired an independent reviewer, neurologist Dr. Graulich, who determined the records contained insufficient evidence of total disability. Based on Graulich’s report, LINA affirmed its decision to deny Cooper benefits. The Sixth Circuit held this denial was arbitrary and capricious for the following reasons:

– The reviewer had been instructed to contract Cooper’s two treating physicians and discuss her case with them. Graulich did not do this.

– Graulich’s report was also misleading in that he determined she should not be disabled from “sedentary” work when her job was actually classified as “light-duty.”

Second Administrative Appeal

Cooper filed a second administrative appeal and submitted additional medical evidence. This time, LINA hired Dr. Sassoon, a physical medicine and rehabilitation specialist to review Cooper’s records with the same instructions to discuss the case with her treating physicians. Sassoon’s report mimicked that of Graulich’s and he also failed to discuss the case with the treating physicians. Relying on Sassoon’s report, LINA again denied Cooper’s request for long term disability benefits. The Sixth Circuit found the denial of the second appeal was also arbitrary and capricious.

District Court Denial of Benefits

Following the denial of her second administrative appeal, Cooper filed an ERISA law suit in federal district court. The Tennessee district court upheld LINA’s decision, commenting that the denial was not arbitrary and capricious even if it was “a decision that others may not have made.” Cooper then appealed to the Sixth Circuit.

Sixth Circuit Reversal of the District Court Decision

For all the reasons discussed, the Sixth Circuit found the denial of benefits was arbitrary and capricious and reversed the decision of the district court. It also noted that the two reports of the reviewing physicians had failed to consider all of the relevant medical evidence that supported Cooper’s claim.

Relying on precedent when determining the appropriate remedy, the court noted that a remand is only necessary “where the problem is with the integrity of the plan’s decision-making process, rather than that a claimant was denied benefits to which he was clearly entitled.” The Sixth Circuit concluded that since Cooper was clearly “disabled under the Plan,” the appropriate remedy was an “immediate award of benefits.” The court ordered benefits to be paid retroactively to the date upon which her “short-term disability benefits ceased.”

This case was not handled by our office, but it may provide claimants guidance on how to persevere when they are continually thwarted in their pursuit of long term disability benefits. If you need assistance with your claim for disability benefits, you may contact any of our lawyers for a free consultation.