The U.S. District Court for the Southern District of Ohio grants the defendant's motion on the administrative record, finding that the decision to terminate long-term disability (LTD) benefits was not in error.
The plaintiff is a former manager of a card and gift store and a participant in the LTD plan of her employer. The plan was governed by the Employee Retirement Income Security Act of 1974 (ERISA). The defendants included the plan and the insurance company that issued the policy for the plan and is responsible for making determinations on claims and appeals. All claims against the plan were voluntarily dismissed, leaving the insurance company as the defendant.
The plan provides that after a 90-day waiting period, an employee is entitled to LTD benefits for the first 24 months of disability if disabled from his or her own occupation. That requirement is met if, as a result of sickness, injury or pregnancy, the individual is unable to perform with reasonable continuity the material duties of his or her own occupation. After receiving LTD benefits for 24 months, an employee may continue to receive benefits only if he or she is disabled from all occupations. An employee is considered disabled from all occupations if, as a result of sickness, injury or pregnancy, he or she is unable to perform with reasonable continuity the material duties of any gainful occupation for which he or she is reasonably fitted by education, training and experience.
The plaintiff became disabled on March 21, 2013 due to suffering from arthritis, nerve problems, a degenerative spinal condition and carpal tunnel syndrome and filed a claim for LTD benefits under the plan. The defendant insurance company conducted a review of the medical evidence and, along with a board-certified doctor, determined that the plaintiff was unable to perform with reasonable continuity the material duties of her own occupation. Therefore, the defendant approved the plaintiff's application for LTD benefits for the initial 24-month period, starting in June 2013. The plaintiff continued to be treated for her neck and back pain during the initial 24-month period.
In April 2014, the plaintiff switched to different doctors, and the defendant insurance company conducted a review of the updated medical evidence; the same board-certified doctor concluded that the plaintiff's medical condition would reasonably preclude light-level work activities. He opined, however, that she would be reasonably...