Uncooperative Benefits Applicant Loses Appellate Legal Battle

The 9 ^th  U.S. Circuit Court of Appeals ruled that   Lumbermens Mutual Casualty Company was correct in denying benefits to plaintiff Linda Gertjejansen who had not attended the required case management conferences while her benefits request was being considered. The decision upheld a ruling by U.S. District Judge Virginia A. Phillips of the U.S. District Court for the Central District of California in favor of the insurer.

Gertjejansen was a nurse case manager handling workers compensation claims when she was involved in a June 2000 auto accident from which she suffered neck and back pain that she said eventually prohibited her from working.   

“It is clear from the record that Gertjejansen did not cooperate with repeated efforts to engage her in case management, making Lumbermens unable to reach a determination that Gertjejansen was disabled,” the 9 ^th  Circuit panel wrote. “It is therefore irrelevant whether Gertjejansen was in fact disabled because her breach of the Plan’s terms prevented such a determination from being made.”

The 9 ^th  Circuit panel also rejected an argument that she should not be penalized for failing to cooperate because the insurer had not shown it had been harmed by her behavior, failing to prove as required by California law that it had been “substantially predjudiced.”

For its part, the insurer argued that it properly relied on a version of the summary plan description that was posted on the company Intranet. The lower court and the appellate panel both rejected that contention, saying that the employer had not submitted evidence proving employees actually received the posted information.

The appellate ruling in Gertjejansen v. Kemper Ins. Companies, Inc., is available  here .