Insurer's denial of ERISA long-term disability benefits is upheld by Sixth CircuitMaribea Balmert sued the Reliance Standard Life Insurance Company to resinstate her disability insurance. An accountant-tax analyst for Big Lots, Balmert also suffered from rheumatoid arthritis. In 2004, she stopped working because of symptoms she believed were related to the arthritis, including pain and numbness in her hands which she attributed to keyboarding demands and stress. Her doctor found little evidence of synovitis in her hands and referred her for neurological and psychological evaluation, while recommending a temporary medical leave. He believed that other potential etiologies needed to be investigated.
Over the course of a year, Balmert was thoroughly worked up and her doctor recommended that she return to work with limitations. The employer refused to allow her to work with those restrictions, however, and she applied for employer-funded disability insurance, through Reliance Standard Life Insurance Company. The therapist who administered a functional capacity assessment to Balmert concluded that she should not return to work and her doctor wrote that he agreed with the therapist's "findings." Reliance granted Balmert only a closed period of several months of benefits, however, based upon its IME doctor's analysis that her arthritis doctor had identified only limited physical findings that would not support a disability.
Balmert filed suit, arguing that Reliance's decision was arbitrary and capricious, that it should have given greater deference to her doctor's opinions, and that she should have been allowed access to the IME doctor's opinion and an opportunity to rebut it. The trial judge rejected Balmert's claim and the Sixth Circuit rejected her appeal. Since she had not requested a copy of the IME doctor's report, the Court denied her standing to argue that Reliance's policy of failing to provide IME reports constituted a lack of due process.
Further, the Court held that Balmert's doctor's endorsement of the Functional Capacity Assessment was ambiguous because the doctor indicated he agreed with the "findings" but did not indcate that he agreed with the reccomendations expressed by the therapist. The Court noted that a treater's opinions are not entitled to due deference, in any event, and concluded that while it was not merely "rubber-stamping" the insurer's decision, the decision was not "arbitrary and capricious."
In a parenthetical, the Court pointed out that while Balmert may have been disabled by stress or other factors, the evidentiary basis for her claim as originally presented to Reliance was rheumatoid arthritis and she had not adequately supported any other basis for arguing a medical disability.