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West Nile Virus: D. Colo

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  • West Nile Virus: D. Colo

    In a recent case from Colorado, the court analyzed the Plaintiff's motion for summary judgment. The Plaintiff sustained brain damage after contracting the West Nile virus that rendered him unable to continue his employment. He was initially approved for both STD and LTD, but his LTD was eventually denied before being reinstated two years later. Then, from 2006 through 2015. the Defendant paid the Plaintiff LTD benefits. Due in large part to a singular neuropsychological test administered in January of 2015, the Defendant concluded that the Plaintiff was no longer disable and therefore not entitled to receive further benefits. After exhausting his internal appeals, the Plaintiff filed suit. The court held as follows:

    As laid out above, I find that the evidence in the administrative record overwhelmingly supports the conclusion that Mr. Paquin?s cognitive ailments caused by West Nile virus are permanent and disabling under the terms of the insurance policy. The evidentiary scoreboard, if you will, reads as follows: 16 healthcare professionals (all doctors of medicine or neuropsychology, aside from one occupational therapist and one speech-language pathologist, and including one doctor who was hired by Prudential) support a finding that Mr. Paquin is disabled; three doctors hired by Prudential found that Mr. Paquin is not disabled under the terms of the policy.
    2 In addition, per ERISA case law the Court views the fact that Prudential paid Mr. Paquin LTD benefits for 11 years while conducting regular reviews as favorable to Mr. Paquin?s claim. As recently as February 2014 Prudential Claim Manager Mary Stratton noted in Mr. Paquin?s file that his cognitive issues were not likely to improve, and that there were no gainful employment options for Mr. Paquin based on the evidence in Prudential?s record.
    With respect to the lone 2015 NPT, the court held:

    Prudential also argues that its decision to terminate benefits is supported by a 2008 NPT performed by Dr. Lemmon to which it only had access in 2015. Drs. Villanueva and Grattan reviewed this NPT and found that it supported Dr. Rippeth?s finding. As a preliminary note, it appears that Prudential was made aware of the 2008 NPT earlier than it alleges. See R. 1276. However, putting the timing issue aside, I do not find this NPT to be the ?significant? evidentiary bombshell Prudential alleges it to be. ECF No. 51 at 6. Even after Dr. Lemmon performed the 2008 NPT in question, she maintained her belief that Mr. Paquin is disabled. Indeed, in 2015 Dr. Lemmon wrote that Mr. Paquin ?is not able to consistently muster and sustain mental effort to successfully maintain gainful employment.? R. 1730. As such, this NPT cannot explain why Prudential suddenly changed course in recognizing the extent of Mr. Paquin?s disability.
    ?[A]n administrator?s decision is reasonable if the administrator based the decision on substantial evidence in the administrative record before it, i.e., that which a reasonable mind might accept as adequate to support the conclusion reached.? Sandoval, 967 F.2d at 381. I do not find that an objectively reasonable mind would find that the Rippeth opinion, supplemented later by the opinions of Drs. Villanueva and Grattan, and the 2008 NPT, in the context of the record taken as a whole, support the termination decision. Prudential appears to have reviewed that evidence with blinders on. The Court will not do so.
    In sum, I conclude that Prudential?s termination decision, in light of the vastly stronger body of evidence to the contrary, was an abuse of discretion. In reaching that conclusion, I weigh, as the law permits, Prudential?s potential conflict of interest as a factor.
    The opinion is attached below.
    Attached Files