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First Circuit Affirms Judgment for Long-Term Disability Administrator Where Evidence of Physical Impairment Was Deficient
Insurance Law Update
First Circuit Court of Appeals
In Richards v. Hewlett-Packard Corp., __ F.3d __, 2010 WL 157480 (1st Cir. (Mass.) January 19, 2010), the First Circuit Court of Appeals upheld Prudential Insurance Company of America’s termination of long-term disability benefits (after 10 years) because there was no evidence that the conditions of fibromyalgia and chronic fatigue syndrome rendered plaintiff Edward Richards unable to perform an occupation for which he was qualified.
In May 1991, Richards, a software engineer, applied for long-term disability benefits under an ERISA-governed plan sponsored by his employer and insured by Prudential. Prudential was also the claim administrator under the plan. Prudential began paying Richards benefits effective July 1991. Prudential thereafter periodically requested proof of continuing disability, as allowed by the plan.
In 2001, Prudential learned that Richards had not seen one of his treating physicians in two years. It sought an independent medical record review from a rheumatologist, who opined that although Richards had fibromyalgia, the information in the file did not support impairment from performing the essential duties of a sedentary job. Richards’ benefits were terminated effective June 1, 2001. Three years later, Richards submitted multiple appeals, and after a review of his claim by Prudential’s medical director and two other independent medical record reviews, Prudential upheld its original decision.
The U.S. District Court for the District of Massachusetts found in favor of Prudential and Richards appealed. The First Circuit affirmed. Reviewing the benefit decision de novo (because the relevant plan documents did not grant discretion to Prudential), the First Circuit found that the reviewing physicians’ opinions that Richards could perform a sedentary occupation were stronger evidence than the opinions of Richards’ treating physician. The First Circuit also stated that the award to Richards of Social Security disability benefits did not mean that he was disabled under the long-term disability plan because his burden to provide disability under the Social Security definition of disability differed from his burden under the plan. The dispute at issue was not over whether Richards suffered from fibromyalgia or chronic fatigue syndrome, but whether these conditions rendered him unable to perform any job for which he was qualified.
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