Magic Words Unnecessary for Benefits
Pippin v. Rock-Tenn Co. Group Ben. Plan, 2016 U.S. Dist. LEXIS 79867 (8th Cir. 2016)
Recently in Fayetteville, AR, the U.S. District Court held that Mr. Charles Pippin was improperly denied short-term disability benefits by his employer, Rock-Tenn Company. Mr. Pippin injured his leg outside of work on February 27, 2014. Thereafter, he sought treatment from his primary physician who ultimately recommended consulting a specialist on the injury and avoiding work until that time. Mr. Pippen visited a specialist on April 10, 2014; at which time, he ordered Mr. Pippen not to work for the following month. During this time, Rock-Tenn denied Mr. Pippen’s claim for short-term disability because the company asserted Mr. Pippen’s doctors had provided “insufficient evidence to establish disability.” Pippin v. Rock-Tenn Co. Group Ben. Plan, 2016 U.S. Dist. LEXIS 79867, 5 (8th Cir. 2016). Rock-Tenn requested more detailed analysis of Mr. Pippen’s injuries than the general doctors’ notes provided. Eventually, Mr. Pippen filed and lost two appeals of Rock-Tenn’s denials of his claims. Rock-Tenn’s denials were supported by the opinions of two different doctors who had reviewed Mr. Pippen’s benefit applications. Those doctors’ opinions focused on Mr. Pippen’s physicians’ omissions of specific medical reasons explaining why Mr. Pippen’s injury disabled him from working.
The court resolved this dispute under the abuse of discretion standard because the ERISA plan at issue allowed for discretionary authority to the plan administrators in determining benefit eligibility. Although courts often give very generous interpretations to the reasonability of plan administrators’ decisions, this court found that the express language of Rock-Tenn’s disability plan called only for the claimant to “provide proof” of the asserted disability. Id. at 20. Even though Rock-Tenn argued the notes provided by Mr. Pippen’s physicians did not meet their desired level of specificity, the court concluded that the orders provided enough information to deem the denial of the benefits to be arbitrary and capricious. The court emphasized that Rock-Tenn’s reviewing physicians’ opinions were flawed in their insistence for additional information from Mr. Pippen’s physician regarding his condition. Furthermore, Rock-Tenn’s doctors failed to indicate why Mr. Pippen’s doctors’ medical opinions should be disregarded so quickly compared to their own. This final point prompted the court to mention that a likely conflict of interest was involved in the denial of Mr. Pippen’s claim by pointing to Rock-Tenn’s exclusive reliance on medical opinions which benefited their interests.
Rock-Tenn had ABUSED it’s Discretionary Authority
In conclusion, the court ruled Rock-Tenn had abused its discretionary authority by denying Mr. Pippen’s claim. Therefore, it ordered that Mr. Pippen be paid the short-term disability payments which had been withheld because the plain language of his ERISA-governed plan did not require any more details concerning his injury than had already been furnished by his doctors. The take-away from this case should to be that there has yet to be an accepted standard established for how specific a doctor’s note must be in order for ERISA short-term disability benefits to be denied.