Published
This month's Friday Five explores the plaintiff's burden of establishing a continuing disability, when state law claims are expressly preempted by ERISA, and the reasonableness of an administrator's interpretation of a preexisting condition policy limitation. It also explores an insurer's obligation to properly evaluate a claimant's occupational specialty and appropriately weigh self-reported symptoms.
The Saul Ewing ERISA Litigation Team
- Will the Eleventh Circuit affirm the district court's award of summary judgment to an insurer after termination of an attorney claimant's long-term disability benefits? Yes, where the plaintiff fails to meet her burden of establishing a continuing disability, an insurance company is not obligated to conclusively rule out a finding of disability and may properly deny benefits. Stacy Hovan ("Plaintiff"), a commercial litigator, filed suit in the Southern District of Florida after Metropolitan Life Insurance Company ("Defendant") terminated her long-term disability benefits and denied her subsequent administrative appeal. After concluding Plaintiff was disabled under her long-term disability plan (the "Plan"), Defendant approved her claim for benefits. Plaintiff was then hospitalized. Upon discharge from the hospital, Defendant reviewed her disability claim and found that her bipolar disorder did not preclude her from performing the functions of her job. However, after multiple unsuccessful attempts to contact her therapist, reviewing her therapist's notes, and hiring a psychiatrist to conduct an independent review of Plaintiff's medical records, Defendant concluded she suffered no impairment in insight and judgment, and therefore, was no longer disabled under the Plan. After conducting a de novo review of the administrative record, the district court upheld Defendant's decision to terminate. The Eleventh Circuit then conducted a de novo review of the district court's ruling and affirmed, as Plaintiff failed to meet her burden of establishing a continuing disability. Specifically, the Court noted that Plaintiff's therapy notes "did not identify any occupational restrictions or cognitive impairments precluding [Plaintiff] from working as a commercial litigator." Hovan v. Metro. Life Ins. Co., No. 24-cv-11167, 2025 WL 3241521 (11th Cir. Nov. 20 2025).
- Will the court dismiss state law breach-of contract-claims where they relate to an ERISA plan? Yes, ERISA's express-preemption clause, 29 U.S.C. § 1144(a), requires ERISA's remedial scheme to supersede state laws that relate to an employee benefit plan. Richard Johnson ("Plaintiff"), was employed by Lantach.com ("Lantach") and participated in a long-term disability insurance plan administered through Lincoln Life Assurance Company of Boston and the Lincoln National Life Insurance Company (collectively, "Lincoln"). Plaintiff became disabled and subsequently entered into a confidential release agreement with Lantach, which Lantach shared with Lincoln. Additionally, Plaintiff was approved for short- and long-term disability under his plan with Lincoln. However, Lincoln withheld disability benefits during the first thirty-seven weeks of eligibility, because it alleged payment by Lantech off-set the amount Lincoln was obligated to pay. Lincoln then ceased payments after concluding Plaintiff was no longer disabled, as updated medical records documenting his continuing disability were not available. Lincoln briefly reinstated benefits, but terminated them a second time to evaluate whether he continued to meet the definition of disability. Plaintiff asserted Lincoln breached its contract by discontinuing payments and failing to make required factual findings regarding his disability status. The court dismissed the claim as it did not seek to correct any violation independent of ERISA, and therefore was expressly-preempted. Further, Plaintiff alleged a breach-of-contract claim against Lantech in part due to its withholding/off-setting long-term disability payments owned to Plaintiff by Lantech's Plan Administrator. The court found this a clear violation of his rights under the benefit plan, which is preempted under § 1144(a). The court therefore dismissed the preempted breach-of-contract claims. Johnson v. Lincoln Life Assurance Co. of Bos., No. 22-cv-626, 2023 WL 12175309 (Nov. 9, 2023).
- Will the Eleventh Circuit find an insurance company's interpretation of a pre-existing condition limitation reasonable? No, the court distinguished receiving medical care for symptoms that are not inconsistent with a preexisting condition and receiving medical care for the preexisting condition itself. After Cherise Johnson ("Plaintiff") visited multiple doctors and was improperly diagnosed a multitude of times, she finally received a proper diagnosis of scleroderma. She subsequently filed a scleroderma-based disability claim, but her insurer, Reliance Standard Life Insurance Company ("Defendant"), denied the claim, as many of the appointments resulting in a misdiagnosis occurred before her policy went into effect, and the policy precluded disability benefits for preexisting conditions. Preexisting conditions were defined as "any Sickness or Injury for which the Insured received medical Treatment…." Plaintiff argued she could not have received medical treatment for a condition no one suspected she had and filed an ERISA suit in district court. The district court granted summary judgment for Defendant and Plaintiff appealed. The Eleventh Circuit found Defendant's denial decision unreasonable. The Eleventh Circuit reasoned that the Defendant's interpretation overlooked the distinction between receiving medical care for symptoms that are not inconsistent with a preexisting condition and receiving medical care for the preexisting condition itself. Defendant's interpretation would mean that an insurer could deny coverage if someone experienced any symptom prior to a diagnosis that was not later deemed inconsistent with such diagnosis. The Eleventh Circuit found this inconsistent with the plain words of the policy and reversed and remanded the action for further proceedings. However, Chief Judge Pryor dissented, finding Defendant's conclusion neither arbitrary nor capricious, as the terms of the policy "contemplate that a condition need not be diagnosed or even suspected to be pre-existing." Johnson v. Reliance Standard Life Ins. Co., --F.4th—(11th Cir. 2025).
- Will a court find a plaintiff is entitled to disability benefits where the defendant insurance company failed to evaluate her occupational specialty, Plaintiff's doctors largely supported her restrictions, and Plaintiff proved objective support for her claim? Yes, these factors will lead to a court reversing a plan administrator's decision. After a difficult pregnancy resulting in lasting complications, Dr. Marla Jahnke ("Plaintiff"), a pediatric dermatologist, claimed disability benefits under her policies with two Unum Group insurance companies (collectively, "Defendants"). Defendants initially paid Plaintiff disability benefits, but subsequently terminated them after finding she was no longer disabled as defined by her policies. Plaintiff subsequently filed suit against Defendants, bringing claims for disability benefits pursuant to ERISA and breach of contract. The court found Defendants' approach to analyzing Plaintiff's occupational requirements as equivalent to general dermatology without proper support was flawed. Further, the court found plaintiff's treating physicians largely supported her restrictions and limitations and Defendants assertions to the contrary were flawed and unsupported. The court also failed to accept Defendants' arguments that Plaintiff's physical activities show she is not disabled, as the activities do not show she could perform the duties of her occupation. The court also evaluated the file reviews of Defendants' medical consultants and opinions of Plaintiff's treating physicians. Ultimately the court found objective support for Plaintiff's claim and entitlement to benefits under the two policies. It did dismiss her state law breach-of-contract claims, as Plaintiff waived any argument through lack of response. Jahnke v. Unum Life Ins. Co. of Am., No. 24-cv-10274, 2025 WL 2603390 (E.D. Mich. Sept. 9, 2025).
- Will the court uphold a denial of long-term disability benefits where the insurer finds the plaintiff's self-reported symptoms not credible, finds that the plaintiff's physicians relied upon the plaintiff's self-reports, and the insurer's independent physician consultants dispute the severity of the plaintiff's disability. No, denial based on these factors will be found to be in error. After being diagnosed with fatigue and memory impairment, Austin Baltes ("Plaintiff") was approved for short-term disability benefits. As Plaintiff neared a long-term disability transition, his claim was transferred to Metropolitan Life Insurance Company ("MetLife"), and his employer, Google LLC ("Google"), provided MetLife with Plaintiff's job description. After MetLife conducted an investigation, including obtaining self-reports from Plaintiff, corroborating medical records, and statements from treating physicians, it denied Plaintiff's claim for long-term disability benefits, finding he was not disabled under the terms of his plan. After an unsuccessful attempt at appeal, Plaintiff filed an ERISA suit in district court, challenging Defendants' denial. The court found Plaintiff's self-reports credible and found that Defendants' ignored his consistent statements and medical reports. Further, the court found the statements of Plaintiff's treating providers reliable evidence of disability and Defendants' dismissal of this evidence in error. The court also found the opinions of MetLife's independent physician consultants to be of little assistance and assigned them minimal weight, as they did not seriously dispute Plaintiff's diagnoses, and instead only contested the severity, based on a paper review. Baltes v. Metro. Life Ins. Co., No. 23-cv-07404, 2025 WL 3199464 (C.D. Cal. Nov. 12, 2025).
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