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Court: United States District Court, Eastern District of Pennsylvania
Insurance Carrier: Reliance Standard Life Insurance Company, or RSLI
Plaintiff’s Employer: Abington Health
Plaintiff’s Occupation: Registered Nurse
Background of the Claim
Lisa Breen, a registered nurse employed by Abington Health, filed a lawsuit against Reliance Standard Life Insurance Company under the Employee Retirement Income Security Act (ERISA). Breen, who was a participant in Abington Health’s employee benefits plan, claimed that her long-term disability (LTD) benefits were wrongfully terminated by Reliance Standard.
Initial Approval and Termination of Benefits
Breen stopped working on July 9, 2018, due to focal epilepsy and other medical conditions. She was approved for LTD benefits on April 4, 2019, after Reliance Standard reviewed her medical records and concluded that she was unable to perform her job duties due to her medical conditions. However, on October 29, 2019, Reliance Standard terminated her benefits, stating that her medical records did not substantiate ongoing impairment preventing her from performing patient care tasks.
First Appeal
Breen appealed the termination of LTD benefits, providing additional medical records and a letter from her neurologist, Dr. Kandan Kulandaivel, which stated that her seizures were unpredictable and left her fatigued. Despite this, an independent physician hired by Reliance Standard, Dr. Zeyad Morcos, concluded there was purportedly no clinical evidence to substantiate Breen’s claims of disabling conditions and that she “had work capacity on [a] fulltime and consistent basis as of September 20, 2019 on light duty.” Plaintiff’s regular occupation required “medium” exertional abilities—i.e., the requirements of her regular occupation exceeded the recommended light exertion restrictions found by Dr. Morcos. Consequently, Reliance Standard reinstated her benefits on January 7, 2020.
Second Appeal
However, this approval was short-lived as Reliance terminated her benefits again on September 28, 2020, on the grounds that she purportedly did not meet the “Any Occupation” standard required to continue receiving benefits after two years.
Breen filed a second appeal, providing further medical records and documentation. As part of her appeal, Breen submitted additional medical opinions and a vocational review. Dr. Skidmore, her treating neurologist, indicated that Breen continued to experience focal seizures and cognitive dysfunction that would prevent her from working.
Despite this, an independent medical review conducted by Dr. James W. Pearce, a neurologist, concluded that Breen’s medical records did not support the limitations claimed. Dr. Pearce emphasized the purported lack of objective evidence, such as EEG results or other clinical findings, to substantiate the severity of her condition.
Reliance Standard conducted a vocational analysis which identified several sedentary occupations that Breen could potentially perform based on her skills and training. These included roles such as Utilization Review Coordinator, Cardiac Monitor Technician, and Rehabilitation Case Manager. The vocational expert concluded that Breen’s medical conditions did not preclude her from performing these alternative occupations.
On June 21, 2022, Defendant sent Plaintiff a letter denying Plaintiff’s appeal. Defendant specifically cited Dr. Pearce’s addendum, which states that “Dr. Skidmore did not provide any new clinical information that would change my prior opinion. No new information was provided for review.”
Plaintiff initiated a lawsuit against RSLI on September 15, 2022.
Court’s Analysis and Decision
The court reviewed the case under the arbitrary and capricious standard due to Reliance Standard’s discretionary authority in interpreting the plan and determining eligibility.
The court found that Reliance Standard’s decision to terminate benefits was reasonable and supported by substantial evidence. The court noted that while Breen’s treating physicians provided opinions supporting her disability, these were largely based on her self-reported symptoms without corroborating objective evidence.
The court concluded that Reliance Standard had conducted a thorough review, including independent medical evaluations and vocational assessments, and had reasonably determined that Breen did not meet the “Any Occupation” standard for continued disability benefits.
The court granted summary judgment in favor of Reliance Standard, and dismissed Breen’s claims.
Get Help with Your Long-Term Disability Claim
Disclaimer: The Ortiz Law Firm did not handle this claim. It is merely summarized here to help claimants understand how Federal Courts handle long-term disability insurance claims.
But this case highlights the challenges faced by claimants in proving ongoing disability under ERISA-governed plans, especially when subjective symptoms are not corroborated by objective medical evidence. If you are dealing with a similar situation regarding the denial or termination of disability benefits, contact us for expert legal assistance in navigating your claim and protecting your rights. Call (888) 321-8131 to get help with your disability claim.
Here is a copy of the decision in PDF: Breen v. Reliance Standard