An employee left her job due to carpal tunnel syndrome. She began receiving benefits under her employer’s self funded ERISA plan. The syndrome became worse, and the employee underwent surgery. She exhausted her short term benefits and applied for long term benefits under the same plan. The plan denied the benefits, and the employee sued. The court applied a de novo standard of review, meaning it examined the evidence from an entirely objective perspective seeking to determine if a reasonable trier of fact would find one way or the other.

The issue was whether the employee was “disabled” as defined by the plan: “unable to perform material and substantial duties of any job for which they are reasonably suited.” Looking at the evidence, the court determined that a reasonable trier of fact would identify the employee as disabled. Furthermore, the plan based its denial only on the analysis of a consulting doctor who did not examine the employee, did not dispute the diagnosis of disablement made by other doctors, and merely discounted the determination of her disabled state on the basis that those opinions were not supported by objective testing. The court found this to be unconvincing since the plan itself did not require the type of objective testing the doctor was looking for.

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This entry was posted by Adam V. Russo on Wednesday, April 4th, 2007 at 4:44 pm and is filed under ERISA, Litigation, Plan Language, Summary Plan Description. You can follow any responses to this entry through the RSS 2.0 feed. You can leave a response, or trackback from your own site.