Can an Employee Seeking Disability Coverage Provide Additional Evidence After the Insurer Denies the Claim?

What should a disabled employee do after their disability insurer denies their long-term disability claim? That issue was recently addressed by a federal appeals court that considered an insurer’s denial of an employee’s disability claim.  There, the employee had to stop working as an insurance sales agent following her struggle with injuries to her back, shoulders, elbows, and wrists. The employee’s condition worsened to the point where she underwent shoulder surgery, however, the procedure did not provide her with any symptom relief. 

After the employee stopped working, she made a claim for long-term disability coverage under her employer-sponsored disability plan. Upon receiving the claim, the employee’s insurer, Lincoln Life Assurance Company, had the employee’s medical records reviewed by a doctor and the claim assessed by a vocation analyst. Based on these reviews, the insurer denied the employee’s claim.

After the denial, the employee did not immediately file a lawsuit against her insurer as her attorney knew she needed to exhaust her administrative remedies with the insurer before being eligible to begin litigation. This is important because the employee’s attorney knew she needed to exhaust her administrative remedies with the insurer before the employee would be eligible to commence litigation. To exhaust her remedies, the employee filed an internal appeal with the insurer.

To support her internal appeal, the employee provided the insurer with additional records not included in the initial claim. These included additional medical records, a functional capacity evaluation, declarations from the employee, a family member, and a close friend, along with a written statement from the employee’s primary care physician responding to the conclusions of the insurer’s doctor. 

The employee’s supplementation of the record ultimately worked to her advantage.  The trial court reviewed her claim and ultimately ruled against the employee, agreeing with the insurer that she was not disabled as defined under the policy. However, the employee eventually appealed the trial court’s decision to a federal appeals court where the appellate court reversed the trial court’s decision and ruled in the employee’s favor.

When the appellate court was considering the employee’s claim, it took into consideration everything that was part of the administrative record. This is important because when the employee submitted additional documentation to the insurer, such as the declarations from the employee, these items became part of the administrative record and could be considered by the court. Had the employee waited to initially submit these items once her case was in litigation, the court would have likely rejected them. Courts often limit their consideration of evidence to those items submitted to the insurer during the claims process.

The type of items the employee submitted were also important.  First, the employee submitted additional medical records.  Medical providers are sometimes slow to provide medical records, so it is important to make every effort to obtain the necessary records that document the disability.  The employee also provided a functional capacity evaluation which is an assessment of the employee’s ability to complete certain physical and/or cognitive tasks that demonstrate whether the employee can satisfy her job functions. Next, the employee provided a declaration of herself which presumably discussed how her limitations affected her ability to work, etc....

The fact that the employee provided statements from friends and family allowed the employee the opportunity to supplement the record with “lifestyle witnesses” that could elaborate on how the employee’s injuries has affected her ability to do her daily activities.  Finally, the employee provided a statement from her doctor that was in response to the conclusions of the insurer’s doctor. By providing a statement from the employee’s doctor, she was able to supplement the administrative record with evidence by a medical professional intimately aware of her medical history. This evidence can be far more compelling than the conclusions of a doctor hired by an insurer to conduct a “paper review” of the claim and never actually examined the employee. 

Ultimately, the employee was able to have the trial court’s decision denying her claim reversed. The employee’s willingness to supplement the record after the initial denial played an important role in building record evidence that ultimately supported the establishment of the employee’s disability claim.

The decision is Collier v. Lincoln Life Assurance Company of Boston, 53 F.4th 1180 (9th Cir. 2022).LOREM IPSUM