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D. Del.: Lots of Moving Pieces but one SJ Motion Granted

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  • D. Del.: Lots of Moving Pieces but one SJ Motion Granted

    In a recent case from Delaware, the facts are interspersed with some odd events. These events include: the Plaintiff, a male, being treated for mental disorders by a Obstetrician-gynecologist; that physician later being unable to provide an opinion after, unsurprisingly, facing criminal charges; and the Defendant insurance company being forced to call emergency services after receiving a call from the Plaintiff who was concerned he may be overdosing on (12) aspirin. Ultimately, however, the court rules in favor of the Defendant's motion for Summary Judgement.

    Circus notes above aside, the opinion is fairly standard. In relevant part:

    Plaintiff contends the decision was arbitrary and capricious because Defendant approved his prior disability claims. (See D.I. 13 at 1) He argues his disability was a recurring illness as evidenced by the other disability claims filed with Defendant for the same illness; all of them approved. (See D.I. 7 at Ex. A1; D.I. 13 at 1) Plaintiff contends that all prior claims were submitted by the same physicians and/or mental health specialists. Plaintiff posits that the record of the prior claim approvals for the same disability substantiates his position that the claim denied in May 2017 was unreasonable and there was no rational basis for denial. (D.I. 13) In the absence of any meaningful evidence to support a change in position, an abrupt reversal in terminating benefits is cause for concern that weighs in favor of finding the denial of an award is arbitrary and capricious. See e.g., Miller v. American Airlines, Inc., 632 F.3d 837, 848 (3d Cir. 2011). Here, Plaintiff provides documentation of approval for prior STD claims in 2012, 2014, 2016, and 2017. (See D.I. 7 at 1-73) However, the prior awards do not warrant a finding that denial of Plaintiff's most recent STD claim was arbitrary and capricious. (See D.I. 7 at 1-75) Contrary to Plaintiff's assertions, the previous STD benefits awarded were not based upon records submitted by the same physicians and mental health providers. Only Dr. Aslam was involved in two of the four prior approved claims. Also, Plaintiff fails to mention that Defendant sought and obtained medical reviews, Plaintiff's medical providers (i.e., Ors. Aslam and Sokoloff) did not communicate with Defendant, and Plaintiff refused to submit to an independent medical examination as requested by Defendant. While the records reflect Defendant's concern that Plaintiff was seen by Dr. Aslam, an obstetrician-gynecologist1 1 the record indicates that, nonetheless, Dr. Aslam's medical records were considered by consultant psychiatrist Dr. Jackson who described Plaintiff as "initially treated by Dr. Aslam, family medicine." (D.I. 11 at 499) Plaintiff's diagnoses in his previous STD claims and the most recent claim are essentially the same; however, given the disparity of evidence among the claims, the lack of documentation in the instant claim, and the various physicians, it cannot be said that the decision to deny STD benefits for the instant claim was arbitrary and capricious. In addition, as will be discussed, the substantial evidence does not support a finding to justify an award of STD benefits.
    Towards the end of the opinion, the court outlines the following:

    In Dr. Jackson's addendum he found that the new information did not convincingly support the presence of any severe psychiatric disorder which would be accompanied by significant functional impairments, restrictions, or limitations as of May 16, 2017 through July 19, 2017. He stated there was: (1) no detailed or measured description of any impairment of attention, concentration, debilitating anxiety disorder, or further description of non-work related functional inabilities; (2) no report of actual or recommended psychiatric treatment in any more intensive level of care; (3) no report of observed adverse effects to prescribed medication; and (4) no record of ongoing evaluation or treatment by a psychiatrist. (Id. at 503) Defendant's decision to deny Plaintiff's STD claim was based on those opinions and, thus, Defendant determined that Plaintiff did not meet the Plan's required definition of disability as of May 16, 2017.
    Ultimately, the court granted the Defendant's motion and denied the Plaintiff's. The full opinion is attached below.
    Attached Files
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