Employee Who Sustained Concussion in Motor Vehicle Accident Awarded Disability Benefits Against Reliance Standard Life Insurance

A federal district court awarded an employee disability benefits and the court’s decision was recently affirmed by the United States Court of Appeals for the Fourth Circuit. There, the employee worked as a financial analyst where her duties included analyzing complex financial management systems, preparing technical evaluations and reports.  Approximately ten years ago, the employee was in a motor vehicle collision. As a result of the accident, the employee sustained injuries to her neck and back as well as a concussion. 

Over time, her condition worsened. Her head injury led to heightened sensitivity to light, sound, and motion. The employee’s condition became so acute that she had to work while wearing headphones to prevent sounds from triggering her symptoms. Eventually, the employee began experiencing slurred speech and had trouble remaining stable while moving about.

The employee initially filed a short-term disability claim with Reliance, however, she soon sought long-term disability coverage. As part of its review, Reliance hired two doctors to review the employee’s medical records.  In his review, the first doctor concluded there was no evidence of an “objective neurological illness.”  Because, the doctor concluded, there was no recognizable neurological disease, he therefore found no evidence of impairment.

Relying on this conclusion, Reliance denied the employee’s disability claim. In response to the denial, the employee filed an internal appeal, however, it too was denied by the insurer.  Reliance denied the appeal based on the opinion of one of its hired doctors who concluded that there was no objective way to evaluate her condition.  By “objective”, the doctor meant there were no diagnostic tests such as a CT scan or MRI that would corroborate her medical condition.

Following the denial of her appeal, the employee sued Reliance in federal court and the judge presiding over the matter ruled in the employee’s favor. In awarding the employee benefits, the federal judge gave greater weight to the employee’s treating doctors who supported her disability diagnosis. Reliance appealed the courts decision to the Fourth Circuit Court of Appeals and that court upheld the lower court’s decision to award benefits to the employee.

The appellate court recognized how the lower court gave greater weight to the opinions of the employee’s treating physicians.  The court noted how the treating physicians saw the employee in person on a regular basis and followed her treatment. The insurer’s doctors, on the other hand, only reviewed her medical records and then issued their decisions.  The court explained how nothing within the ERISA statute requires that a court give special deference to a disabled employee’s treating physicians, however, there is nothing preventing a court from giving greater weight to the opinions of the insured’s treating doctors. 

Based on the evidence presented, the appellate court found that the lower court had reached reasonable conclusions; therefore, the employee was entitled to disability benefits under the policy.  This decision reminds us that courts are often mindful of the broader understanding a treating physician has for a disabled employee’s medical condition. This does not suggest that courts ignore the conclusions of the insurer’s reviewing doctors. Instead, it shows opportunities for disabled employees to draw a distinction between the in-depth understanding a treating physician has compared to an insurance company’s reviewing doctor merely looking at medical records and failing to examine the patient.

The decision is Tekmen v. Reliance Standard Life Ins. Co., 55 F4th 951 (4th Cir. 2022).