Insurance: Record supports denial of short-term disability benefits

Where the record supported the insurer’s denial of short-term disability benefits, it was affirmed.

Background

Nicholas Wray brought this action against the Life Insurance Company of North America’s, or LINA, and his former employer, The West Monroe Partners Inc., over his claim for short-term disability, or STD, and long-term disability, or LTD, benefits. Defendants have filed motions for summary judgment and Wray has filed a motion for judgment on the administrative record.

LTD claim

LINA first argues that Wray failed to exhaust his administrative remedies on his LTD claim. The court agrees.

The record does not show any evidence that Wray initiated a claim pursuant to the LTD policy’s requirements for notice: neither Wray’s “Supplement to Appeal” nor his cover letter included Wray’s LTD policy number or address, as was required by the LTD policy. Nor does the record show that Wray or his counsel’s actions put LINA on notice that Wray properly initiated a claim under the LTD policy.

Even had Wray initiated an LTD claim with his “Supplement to Appeal,” the claim would be untimely under the LTD policy. The LTD policy sets out time constraints for the initiation of claims: notice must be provided to LINA “within 31 days after a covered loss occurs or begins or as soon as reasonably possible.”

At the latest, Wray’s symptoms began on Dec. 1, 2022. It was only on July 12, 2023 that Wray attempted to initiate an LTD claim. Because Wray did not meet LINA’s deadline for initiation of a claim, and because Wray does not argue that the filing was undertaken “as soon as reasonably possible,” the court finds that Wray did not provide timely notice to LINA of his LTD claim.

Finally, even if the court construes the July 12 “Supplement to Appeal” as proof of loss, Wray’s filing falls well outside of the 90-day window for filing. The court will grant LINA’s motion for summary judgment as to the LTD claim.

STD claim

Because the STD plan provides discretionary authority to LINA to determine eligibility for benefits, the court will use the abuse-of-discretion standard. Under this highly deferential standard of review, the court looks to see if LINA’s decision followed a “deliberate, principled reasoning process” and is “supported by substantial evidence.”

Wray takes issue with LINA’s failure to conduct a formal vocational review, which Wray argues rendered it “impossible for LINA to ‘distill the medical and vocational evidence, apply it to the occupational profile, and make a reasoned determination’ regarding Mr. Wray’s disability.” But none of LINA’s reviewing doctors found that Wray was functionally limited in any way and accordingly did not recommend any activity restrictions. Failure to perform a vocational assessment in these circumstances does not plainly contradict the language of the plan.

The court finds there are sufficient facts in the record to support LINA’s finding that Wray was not disabled: the test results; Wray’s providers’ observations of his intact judgment and normal cognition and his self-reported ability to perform complex tasks. Weighed against Wray’s self-reported symptoms, the opinions of medical providers based solely on those self-reported symptoms and the results of a neuropsychological evaluation that indicated possible malingering, LINA’s decision reasonably supported by the materials considered in its evaluation.

The court also finds that that LINA’s decision-making was reasoned and principled. LINA  provided  Wray  with  multiple  opportunities  to  provide  additional  medical documentation, including during his appeal process. LINA employed three specialist physicians to undertake independent reviews of Wray’s claim. LINA issued lengthy letters describing the reasoning for its decision and including the opinions of its reviewing physicians. LINA’s benefits determination is not unreasoned or unprincipled merely because it did not result in the outcome Wray desired.

Wray also suggests that LINA’s failure to request an independent medical examination “raises serious concerns about the thoroughness and accuracy of [LINA’s] benefits determination.” The STD plan allows LINA “the right to examine any person for whom a claim is pending as often as it may reasonably require.” It does not impose upon LINA an obligation to conduct such an examination.

Plaintiff’s motion for judgment on the administrative record denied. Defendants’ motions for summary judgment granted.

Wray v. Life Insurance Company of North America, Case No. 5:23-cv-00060, Apr. 15, 2025. WDVA at Harrisonburg (Yoon). VLW 025-3-162. 48 pp.