On April 18, Gordon & Rees partner Ronald K. Alberts and associate Hilary E. Feybush of Los Angeles won a judgment for the defendant-insurer after filing trial briefs and presenting oral argument before the U.S. District Court for the Central District of California. Alberts and Feybush successfully argued that under the Employee Retirement Income Security Act of 1974 (ERISA) the insurer’s denial of disability benefits should be upheld under the de novo standard of review.
The lawsuit arose out of the denial of the plaintiff’s claim for short-term disability benefits under a fully insured disability benefits plan. The plaintiff applied for disability benefits after his employer placed him on extended medical leave of absence, two years after he had suffered a brain injury from an automobile accident. Based on the medical records and two independent physician reviews that concluded the plaintiff was not disabled, the insurer denied the plaintiff’s claim for disability benefits because the medical information lacked sufficient objective clinical findings to support a disability. The plaintiff appealed the insurer’s decision.
At the March 31 trial, Gordon & Rees argued that the plaintiff did not meet his burden of proof in establishing he was disabled and that the insurer correctly denied benefits under the de novo review.
In its order, the court agreed with Gordon & Rees’s arguments and found that the insurer reached the correct decision in denying the disability benefits. The court found that it was reasonable for the insurer to discount the report of the plaintiff’s treating physician that stated the plaintiff was totally disabled from work if modified activity was not accommodated by the employer since the physician was not in the right specialty and had acknowledged he made this recommendation without being familiar with the plaintiff’s job description.
In addition, the court found that the insurer extensively reviewed the plaintiff’s medical records and engaged in meaningful dialogue with the plaintiff. While the court found there was some evidence that the plaintiff suffered from a mild brain injury, “most importantly, there is no credible evidence that this medical condition disabled [the plaintiff] from fulfilling the material duties of his particular job. Therefore, it was reasonable for [the insurer] to deny [the plaintiff’s] claim under the Policy.”
Based on this ruling, the plaintiff is not entitled to disability benefits from the insurer.