Elam v. Anthem Life Insurance Company

Background

Eileen Elam sued Anthem Life Insurance Company under the Employee Retirement Income Security Act (ERISA), specifically 29 U.S.C. § 1132(a)(1)(B), challenging Anthem’s denial of short-term disability and long-term disability benefits. The insurance plan was provided through Elam’s former employer, Overland Storage, Inc., as part of the Overland Storage, Inc. Welfare Benefit Plan.

Elam worked as Overland’s director of marketing. Her work involved branding and messaging, maintaining the company’s website and social-media accounts, interacting with the press, and working long hours, mostly at a computer. The court found that her occupation required a full-time commitment and up to six hours of uninterrupted computer work.

Elam suffered a concussion in a mountain-biking accident on April 2, 2016. She later reported fatigue, dizziness, poor balance, headaches, difficulty concentrating, sensitivity to light, blurry vision, anxiety, and depression. She stopped working entirely on August 14, 2016, and unsuccessfully attempted to return to work part-time. Anthem denied her claim, upheld that denial on appeal, and did not consider her request for long-term disability benefits because it had not approved benefits through the plan’s maximum short-term disability period.

The Social Security Administration later approved Elam’s disability claim for the relevant period. Anthem stated that the Social Security decision did not change its decision. Elam then brought this case.

Standard of Review

The parties agreed that the court would conduct a de novo review, meaning the court independently evaluated the administrative record and decided whether Elam was entitled to benefits under the plan. Elam had to prove by a preponderance of the evidence—meaning that it was more likely than not—that she was disabled under the plan’s terms.

The court explained that a diagnosis alone does not establish disability. The relevant question was whether Elam’s conditions prevented her from performing the material and substantial duties of her occupation. The court also considered the evidence before Anthem when it made its decision. Because Anthem had stated that it considered the Social Security determination, the court treated that determination as part of the administrative record, although it was not binding on the court.

Analysis

The court rejected Elam’s challenges concerning the plan’s self-reported-symptoms provision, Anthem’s consideration of her job duties, the lack of physical examinations by Anthem’s medical reviewers, and the reviewers’ division of issues among different medical specialties.

The court concluded that the self-reported-symptoms provision appeared in the long-term disability portion of the plan, not the short-term disability portion. The provision allowed long-term disability benefits to be paid based on certain self-reported symptoms, including fatigue, dizziness, and loss of energy, for up to 24 months, but it did not require payment based solely on those symptoms.

Period of Disability

The court found by a preponderance of the evidence that Elam was disabled from August 15, 2016, through July 4, 2017. It relied on the combination of her post-concussion symptoms, vestibular problems, anxiety, and depression; treatment records; physician work restrictions; third-party observations; and the requirements of her occupation. The court found it more likely than not that these conditions left her unable to work full-time and use a computer uninterrupted for up to six hours per day.

The court gave somewhat more weight to the opinions of Elam’s treating physicians for this period because they had greater opportunity to observe her than Anthem’s reviewing physicians. The court also found some of Anthem’s medical opinions persuasive but concluded that the evidence supporting disability through July 4, 2017, was slightly more persuasive.

The court found that the record did not establish disability after July 4, 2017. It questioned the support for later work-status reports from Dr. Rob, including reports based on a short telephone call or lacking an adequate assessment. The court also noted that Elam discontinued vestibular therapy in September 2017 and found that the evidence did not sufficiently establish disabling functional limitations after July 4.

Disposition

The court granted in part and denied in part Elam’s motion for judgment under Rule 52 and granted in part and denied in part Anthem’s motion for judgment under Rule 52. The court found that Elam was disabled under the plan from August 15, 2016, through July 4, 2017, but that the record failed to establish disability after July 4, 2017. The parties were ordered to meet and confer and submit a stipulated proposed judgment consistent with the order by September 16, 2021.