Lack of Proof of Good Health Reason for LTD Benefit Denial

May 18, 2006 ( - The US District Court for the District of Massachusetts has upheld a long term disability plan administrator's denial of increased benefits to a participant who failed to provide evidence of good health.

In its decision, the court said the administrator did not act arbitrarily in denying increased benefits since Karen Brilmyer failed “to develop any record evidence to affirmatively establish her good health.” She therefore did not meet her burden to establish eligibility under the terms of the plan.

In addition, the court said the fact that Standard Insurance Company knew she was already disabled and receiving benefits under a base LTD plan did not proof they had a conflict of interest when reviewing her eligibility for increased benefits.   Even if it did, according to the opinion, that would not change the fact that Brilmyer did not prove her good health and eligibility for the plan.

Brilmyer worked for the University of Chicago which provided a group life insurance and LTD plan.   The LTD plan had two tiers, a base and optional plan, and participants could only be enrolled in one or the other. The optional plan provided more generous benefits.

Brilmyer was enrolled in the base LTD plan and the life insurance plan, the court document states. During an open enrollment period, she applied for increased life insurance benefits and the optional LTD plan. The plans required proof of good health in order to be eligible for increased benefits.   In a statement of health form Brilmyer noted she was taking Zoloft and within the prior five years had been treated and released for post-traumatic stress disorder and an injured neck.

TIAA, who was the plans’ administrator at the time, asked her for more details on her conditions, which she did not provide, according to the opinion.   The administrator then issued her a letter denying her increased benefits.   The subject of the letter mentioned only the life insurance plan.   Brilmyer assumed she was approved for the optional LTD plan, even though no additional premiums were taken from her paycheck.

After a head injury rendered her disabled, she began receiving LTD benefits under the base plan. Standard had assumed administration of the plans, and she contacted them concerning her increased benefits. She was informed that Standard was upholding a previous denial of coverage from TIAA.   Brilmyer asked Standard to review TIAA’s decision.   After two reviews, she again was denied eligibility for the optional plan due to “substantial evidence of significant medical problems, ranging from the minor and sporadic to the significant and persistent,” according to the opinion.

Brilmyer sued and the district court granted summary judgment in favor of the University and Standard.

The opinion in Brilmyer v. University of Chicago is here .