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Substantial Evidence Must Support Termination of Benefits

In another Fourth Circuit case, it found a plan abused its discretion by terminating long term disability benefits because the administrator's analysis did not adequately account for medical evidence regarding the claimant's inability to use her hands and perform her occupation as a customer service clerk. The Court reasoned that the insurance company's decision was not supported by substantial evidence because the claim file contained overwhelming evidence reflecting significant problems with the claimant's hands and wrists, including nine medical procedures to treat her condition and continued pain as a result of those conditions. The Court concluded that even under the deferential abuse of discretion standard, the insurance company's rationale for terminating the claimant's benefits was not reasoned and principled and was not supported by substantial evidence because in its initial termination letter it did not address evidence from the claimant's treating physician concerning her inability to use her hands to conduct the typing and other activities required by her customary occupation. The doctor consulted by the insurance company on appeal did not accurately evaluate the claimant's inability to use her hands, disregarding numerous instances in the record in which the claimant experienced pain and difficulty to attempting to use her hands.

Fair Evaluation of All Disabling Conditions

The Fourth Circuit also insists that it is necessary to evaluate all of a claimant's disabling conditions, in conjunction with each other, not just a select few. The claimant had her own declaration and declarations from family members and former employers confirming the severity of her symptoms. The insurance company obtained a review by a doctor who did not examine the claimant and his report contained no significant basis, supporting a conclusion that the symptoms from the claimant's fibromyalgia, either by itself or combined with the symptoms from other conditions, were not sufficiently severe to prevent her from working a full work week.

Benefits Changing from Own Occupation to Any Occupation

Also, the Fourth Circuit held that the claimant is entitled to benefits from the date of termination of benefits to the date of judgment even though in that time frame the definition of disability changed from the own occupation definition to the any occupation definition. The Court explained that the claimant could hardly be blamed for not applying for benefits during the any occupation period. The Court also reasoned that even though the insurance company had not yet passed on the question of whether the claimant satisfied the any occupation standard, there was no indication that the changed standard would affect the result because it was apparent from the record that the claimant's inability to work was not the result of particular duties specific to her regular occupation.

The Fourth Circuit, like most circuits, has not yet expressly ruled on the availability of conflict of interest discovery. However, district courts within the Fourth Circuit have permitted conflict of interest discovery.

Involve an ERISA Lawyer Who Serves the Fourth Circuit

ERISA Law Center serves the Fourth Circuit by representing claimants in the following states and cities: Maryland: Baltimore, Columbia, Germantown, Silver Spring, Waldorf, Glen Burnie, Ellicott City, Frederick, Rockville and Bethesda; North Carolina: Charlotte, Raleigh, Greensboro, Winston-Salem, Durham, Fayetteville, Cary, Wilmington and High Point; South Carolina: Columbia, Charleston, North Charleston, Mount Pleasant, Rock Hill, Greenville, Summerville, Sumter, Hilton Head Island, Florence and Spartanburg; Virginia: Virginia Beach, Norfolk, Chesapeake, Arlington, Richmond, Newport News, Alexandria, Hampton, Roanoke and Portsmouth; and West Virginia: Beckley, Charleston, Clarksburg, Fairmont, Huntington, Martinsburg, Morgantown, Parkersburg, Weirton and Wheeling.