Termination of Benefits Permitted Based on Objective Medical Evidence.

 
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The U.S. District Court for the Northern District of Indiana grants the motion for summary judgment by the defendant insurance company and denies the cross-motion by the plaintiff, finding that the termination of long-term disability (LTD) benefits is supported by a reasonable explanation based on objective medical evidence.

The plaintiff is the former director of operations at a casino and hotel who was covered under his employer LTD insurance policy. The defendant is the insurance company that issued the policy and to which the employer delegated discretionary authority to make benefit determinations.

The plaintiff was diagnosed with human immunodeficiency virus (HIV) in 1986 but continued working for many years thereafter, eventually retiring in July 2013 due to chronic symptoms of HIV including neuropathy, cognitive impairment, chronic fatigue and depression.

The policy has a test for disability requiring that an individual cannot perform the "material duties of your own occupation solely because of an illness, injury or disabling pregnancy-related condition" for the first 24 months and then, thereafter, if the individual is "unable to work at any reasonable occupation solely because of an illness, injury or disabling pregnancy-related condition."

The defendant initially denied the plaintiff's claim for LTD benefits but ended up approving monthly benefits under the policy during the initial 24-month own occupation period. The defendant then conducted a medical review and determined that none of the medical evidence supported a finding that the plaintiff could not work in any occupation and, in fact, it supported a finding that the plaintiff could do other full-time sedentary work.

In addition to relying on medical reports from various doctors, the defendant also conducted an independent investigation in which it determined that the plaintiff had actually started two new real estate businesses and obtained his real estate license after he stopped working at the casino. As part of conducting the two new businesses, the plaintiff also drove approximately 2,400 miles per month, which was indicative of having the cognitive, mental and physical capacity and...

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