Fredrick Smith worked as a plant manager for Charles Craft, Inc. in North Carolina. He held that position since 1970, but he was forced to leave by 2013 due to a series of strokes and heart problems. Smith applied for disability benefits with Reliance Standard under his employer’s ERISA plan. At first, Reliance paid benefits, but after some time, Reliance revised its decision and insisted that Smith could work at another job. Smith appealed the new denial.

Smith’s Health Condition Gradually Deteriorates

Although Smith’s long-term disability claim denial did not start until 2016, his health conditions had actually been getting worse for several years before he stopped work. In 2012 and 2013, Smith was having difficulty breathing because he had diabetes, high-grade stenosis, and hypertension. He had two strokes during that type as well. In early 2013, he suffered a heart attack. Doctors diagnosed him with coronary artery disease, which was the same disease that killed his father when he was just 44.

Despite his health issues, Smith continued to work on a part-time basis. He went through a triple bypass surgery, which caused his left hand to go numb occasionally and feel as if it were freezing. Finally, his doctors insisted that he completely stop work. His employer agreed and took additional steps to avoid causing Smith undue stress that could make his condition worse.

The Application Process with Reliance

In July 2013, Smith applied for disability benefits through Reliance Standard. Smith’s doctor noted that Smith could never return to work because of his health conditions. Reliance approved Smith’s application in August 2013.

Smith also applied for Social Security disability benefits in September 2013. He was awarded benefits, which, in turn, reduced the amount that Reliance would have to pay in benefits every month.

Smith’s Continuing Coverage

As is standard procedure, Reliance periodically requested additional health information from Smith to determine whether his health had gotten any better and whether he was still entitled to long term disability benefits. Smith’s health conditions continued to get worse throughout 2014. He developed nerve problems, numbness, and neuropathy. He had slurred speech, facial drop, poor balance, memory problems, and difficulty with stress that his doctors attributed to an additional stroke. He also had problems with hives and swelling from taking his diabetes medicine. He had trouble sleeping and was too ill to even enjoy recreational activities, like golf. Smith’s doctors rightfully refused to provide an end-date for his disability, noting that he was “permanently” disabled.

Despite significant evidence of Smith’s worsening health condition, Reliance decided to deny LTD benefits beginning in August 2015. One of Smith’s functional testing results indicated that he could do sedentary work, so Reliance concluded that because of his, Smith was not totally disabled. Part of their denial was based on a note from Smith’s doctor that Smith “walks up to 40 miles without difficulty.” However, Smith explained that he had been tracking his walking from Christmas to April with a Fitbit that Smith received as a Christmas gift. Smith provided letters from several doctors, and Reliance decided to reverse its decision and continued to pay benefits.

After that, Smith’s kidney disease got worse, and he was required to put a urological stent in place. He developed kidney stones and his chest pain returned. He also had to have a drug-eluting stent put in for his heart as well.

Again, despite Smith’s worsening condition, Reliance denied LTD benefits in April 2016. It did so because of notes from Dr. Klang, a heart specialist that Smith was seeing. Dr. Klang noted that Smith was walking 7 or 8 miles a day without a problem. It also included general notes that Smith was “doing well from a cardiac standpoint” and “blood pressure appears controlled.”

A third-party doctor, Dr. Weston, evaluated Smith’s records. Dr. Weston tried to contact Smith’s doctors, but he was unable to do so. Based on Dr. Klang’s records and Dr. Weston’s review, Reliance again stopped benefits, noting that Smith was no longer disabled as of June 2016. Smith appealed.

Smith contacted Dr. Klang, and Dr. Klang clarified that Smith could only walk half of a mile a day and that references to him walking eight miles were incorrect. Nonetheless, Reliance noted that the rules under its disability insurance policy only permitted one appeal, which Smith had already used, and they closed their record. As a result, Smith was forced to file a lawsuit to seek further benefits.

The Court Highlights the Importance of Accurate Records

The District Court agreed with Smith, noting that the Reliance ignored most of the medical evidence presented to it when it denied his claim for continuing benefits. If they had contacted Dr. Klang, he likely would have corrected the errors in the medical records.

The United States Court of Appeals for the Fourth Circuit discussed the court’s role in evaluating Reliance’s decision. Specifically, the Court needed to look at the evidentiary support that leads to the administrative decision. The Court stated: “Reliance agrees that Smith is too ill to return to his job at Charles Craft, but maintains that a job with less lifting and stooping than a plant manager would suit him. This view defies belief.” It then went on to outline Smith’s extensive medical history, noting that “[e]very doctor that examined him told Reliance he would never be able to work.”

While the court noted that a treating doctor’s opinion may not necessarily carry more weight than a third-party doctor, evidence supplied by treating doctors cannot be ignored. They emphasized the ridiculousness of the possibility that Smith could walk 40 miles per day or even per week from the first denial and that Reliance should not place much stock in doctor’s general comments that Smith was “doing well” or similar notes.

The Court concluded that Smith was not required to prove that he could not do sedentary work. They noted that such a standard would be far too high and that “[s]uch a rule would erase disability eligibility for all but the bedridden.” Ultimately, the Court of Appeals agreed with the District Court, and benefits were ordered to continue.

This decision highlights the importance of gathering and presenting evidence of medical conditions for a disability appeal. Although Dell & Schaefer did not handle this case, we see this type of fact pattern happen frequently. The insurance company cannot ignore evidence to make its decision. If you need help with a similar matter, please contact any of our lawyers for a free consultation.