The Standard Reversed for Ignoring Medical Evidence and Improper Denial

Marcin v. Reliance Standard Life Ins. Co., No. 16-7125, 2017 WL 2818648 (June 30, 2017).

Affirming the judgement of the district court, the United States Court of Appeals for the District of Columbia held that Reliance Standard Life Insurance Company acted unreasonably when it failed to properly consider the downward progression of one of its insured’s health, as well as her work history. The plaintiff, Jill Marcin, was diagnosed with multiple medical conditions including kidney cancer and anemia. While she treated for these conditions her doctors released her to work on an “as tolerated” basis. Unfortunately, as her diseases progressed, Ms. Marcin attended work less and less frequently. During this time she was never able to work a normal 40-hour week. RLS’s LTD plan treated a finding of “partial disability” the same as “total disability” when they concluded she was able to work 100% of the time since she was working on a part-time basis. While in some instances Ms. Marcin’s treating physicians would note that she was “feeling better,” the overall progression of her conditions was negative. RSL denied Ms. Marcin’s claim for long term disability benefits on the grounds that she was not “totally disabled” under the plan. RSL supported this decision by cherry picking instances from Ms. Marcin’s medical record that stated she was doing better, and by noting that she was cleared to work by her doctors on an “as tolerated” basis. RSL also heavily focused on two paid medical reviews that found Ms. Marcin was able to complete full time work.

The Court of Appeals held that it was unreasonable for RSL to determine that Ms. Marcin was capable of full-time work since her work history clearly showed that she was continuously incapable of completing a normal 40-hour week. The Court noted that RSL’s decision was not supported by the record because it “entirely failed to acknowledge the fact that Ms. Marcin never worked full time” and that her hours declined sharply. RSL completely failed to address the fact that over time Ms. Marcin’s fatigue progressed from “mild” to “extreme,” and the Court deemed this to be further proof of unreasonable conduct. RSL could not claim that Ms. Marcin was capable of full-time work when the record clearly showed she was barely capable of any work.  The Court also took issue with the paid medical reviews relied on by RSL in their denials. One medical review was deemed to be unreliable by the Court because it failed to address Ms. Marcin’s work history, and also failed to dispute the findings of her treating physicians. The review was also deficient in that it completely failed to explain how its “conclusions are rationally related to the medical evidence.” The Court stated “It is hard to mark a review as reliable when the examination is not linked to the overall medical history” and that “the selective description of medical evidence undermines the reliability” of the paid review.