In Ray v. Sun Life & Health Insurance Company, No. 10-14693 (11th Cir. 2011), the plaintiff, Myra Ray ("Ray"), was appealing the district court's affirmation of a decision to terminate her long-term disability ("LTD") benefits . Ray was covered at work under an LTD plan (the "Plan"). The Plan was administered by the defendant, Sun Life & Health Insurance Company ("Sun Life"). Ray claimed LTD benefits under the Plan, on the grounds that she had become totally disabled due to a heart condition. The claim was approved by Sun Life, and she was awarded the LTD benefits.
However, Ray was advised that periodic medical updates would be required to verify that she remained totally disabled. Ray's doctor confirmed her disability in statements sent to Sun Life. But the doctor's office notes often were inconsistent with the disability statements submitted to Sun Life. The office notes suggested that Ray's condition was much improved, that she suffered far fewer symptoms than was represented to Sun Life, and that she was capable of -- and engaged in -- much more activity than the disability statements disclosed. Sun Life ordered surveillance of Ray's activities on two separate dates. The surveillance videos showed Ray engaged in activities with a fluidity of movement, without need of assistance, and without apparent effort. The video contradicted Ray's own doctor's representations of Ray's limitations in the disability statements he submitted to Sun Life. Sun Life engaged two physician of its own to evaluate Ray's medical records and the surveillance information. Although they did not physically examine Ray, both physicians concluded that Ray was capable of returning to her own occupation. Prior to Sun Life's rendering its final decision, Ray was awarded disability benefits by Social Security.
Based on the foregoing, Sun Life concluded that, notwithstanding the Social Security determination, Ray was not totally disabled within the meaning of the Plan. Therefore, it decided to terminate Ray's LTD benefits, and this suit ensued under ERISA. The question for the Eleventh Circuit Court of Appeals (the "Court"): can it disturb Sun Life's decision to terminate Ray's LTD benefits?
Since the Plan gave it discretionary authority to determine benefit claims, Sun Life's decision to terminate the LTD benefits is entitled to a deferential review. However, in analyzing the case, the Court said that the district court had concluded that Sun Life's decision was not even de novo wrong. The Plan defines totally disabled as "unable to perform all the material and substantial duties of your regular occupation." The items and reports in the case's record (discussed above) establish that Ray was not disabled, as so defined, and even Ray's own doctor's office records contradict his conclusion of disability. Sun Life's own doctors-two medical experts- both opined that Ray was capable of returning to her own occupation. The opinion of a plaintiff's own treating physician is not entitled to special weight. While approval of social security benefits may be considered, it is not conclusive on whether a plaintiff is also disabled under the terms of an ERISA plan. The Court agreed with the district court that Sun Life's decision to terminate the LTD benefits was not de novo wrong. Accordingly, the Court upheld Sun Life's decision and the district court's affirmation of it.