Background
Mr. Vilasack Vongkoth worked as a hand grind/production grinder for PCC Structurals Inc. (“PCC”). In October 2020, he became ill with a severe infection as a result of a liver abscess and was paid short-term disability (“STD”) benefits from October to December 2020.
However, Life Insurance Company of North America (“LINA”)/Cigna Insurance Company of North America (“CIGNA”), the company in charge of administering the STD plan, terminated Mr. Vongkoth’s STD payments after December 4, 2020, on the basis that he failed to show a continued disability.
Mr. Vongkoth submitted an appeal to LINA with additional evidence of disability, including treatment records and multiple forms and letters from his doctors stating that he could not return to work because of the severity of his ongoing symptoms.
LINA denied Mr. Vongkoth’s appeal relying on one medical records review completed by its consulting physician. Following the denial of his appeal, Mr. Vongkoth filed a lawsuit in federal court against his employer PCC (who sponsors and funds the STD Plan and is considered the Plan Administrator under ERISA).
The Court’s Review
The Court denied PCC’s motion for summary judgment, finding there were “serious questions” about whether LINA’s decision to terminate STD benefits was reasonable. Specifically, the Court noted that all of Mr. Vongkoth’s treating doctors (3 in total) unequivocally concluded that he was not able to work far beyond December 2020.
In contrast, the only doctor who found Mr. Vongkoth was able to return to work was LINA’s medical reviewer. The Court found this stark difference in opinion raised questions about the reasonableness of the medical reviewer’s opinion, especially since he was the only doctor who did not personally examine Mr. Vongkoth or speak with any of his treating doctors.
The Court also rejected LINA’s attempt to downplay the treating doctors’ conclusions as based only on Mr. Vongkoth’s self-reported symptoms. Importantly, while the Court agreed that some of Mr. Vongkoth’s symptoms (such as racing heart, fainting, and fatigue) are temporary and difficult to record, the Court concluded that his treating doctors are in a much better position to assess the credibility of his self-reported symptoms.
The Court’s decision is significant as it cuts against an insurer’s ability to support its denial of disability benefits based solely on a paper review, especially when that opinion is contrary to the conclusions of numerous treating physicians. The Court’s decision is also significant as it prohibits an insurer from downplaying a treating doctor’s opinion when it is based, in part, on self-reported symptoms.
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