Robertson v. Standard Insurance
139 F. Supp. 3d 1190
| D. Or. | 2015Background
- Plaintiff Sherry Robertson sought ERISA LTD and waiver-of-premium life coverage benefits from Defendant Standard Insurance, beginning September 4, 2012 and ending October 18, 2013.
- Defendant terminated LTD benefits on October 18, 2013, asserting Robertson no longer met the disability definition.
- Plaintiff moved for judgment on the record or summary judgment, seeking retroactive reinstatement of LTD and waiver-of-premium benefits.
- The LTD policy pays 60% of pre-disability earnings for 24 months, with an Own Occupation period requiring inability to perform material duties of own occupation.
- Defendant relied on Dr. Hart’s file review and did not adequately account for the SSA’s June 2, 2013 fully favorable disability decision.
- Treating physicians consistently diagnosed disability; a December 2, 2013 FCE suggested sedentary capability, but its timing and weight were disputed.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Whether the LTD termination was an abuse of discretion. | Robertson contends the decision relied on incomplete evidence and ignored prior disability findings. | Standard asserts proper reliance on the record and the treating evidence, with discretion to terminate. | Yes; termination was an abuse of discretion. |
| Whether the plan administrator’s structural conflict of interest merits heightened scrutiny. | Conflict as insurer and administrator taints decision-making. | Conflict weighs as a factor but does not alone justify reversal. | Conflict weight deemed insufficient to negate overall abuse finding. |
| Whether an independent medical examination (IME) was required or neglected. | Defendant failed to obtain an IME, relying on paper reviews. | IMEs are not mandatory; paper reviews permissible. | Failure to obtain an IME weighed in favor of abuse of discretion. |
| Whether SSA’s favorable determination was adequately considered. | Defendant ignored SSA’s disability finding and related records. | SSA decision not binding but should be weighed; consideration was insufficient. | Defendant’s inadequate consideration of SSA findings supported abuse finding. |
| Whether reinstatement of benefits is appropriate. | Given the record, continued benefits should be reinstated. | Remand or continued denial pending further evidence. | Reinstatement of benefits granted. |
Key Cases Cited
- Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101 (U.S. 1989) (establishes abuse-of-discretion standard under ERISA when discretionary authority is granted)
- Abatie v. Alta Health & Life Ins. Co., 458 F.3d 955 (9th Cir. 2006) (conflict of interest permissible to consider evidence outside the record)
- Montour v. Hartford Life & Accident Ins. Co., 588 F.3d 623 (9th Cir. 2009) (multi-factor analysis for abuse-of-discretion review with conflict of interest)
- Salomaa v. Honda Long Term Disability Plan, 642 F.3d 666 (9th Cir. 2011) (confirms factors in evaluating discretionary decisions and impact of evidence)
- Saffon v. Wells Fargo & Co. Long Term Disability Plan, 522 F.3d 863 (9th Cir. 2008) (discusses insurer’s duty to consider ongoing evidence and prior reliance on benefits)