Eighth Circuit Finds Abuse of Discretion When Insurance Company Stopped Payments of Anesthesiologist's Disability Benefit After 10 Years

Yesterday, the Eighth Circuit Court of Appeals decided?Roehr v. Sun Life Assurance Co. of Canada,?No. 21-1559, 2021 WL 6109959 (8th Cir. Dec. 27, 2021) , a matter involving a denied long-term disability (“LTD”) benefit claim under the Employee Retirement Income Security Act (“ERISA”).

Plaintiff-Appellant Todd Roehr worked as a board-certified anesthesiologist for twelve years before he stopped working due to intermittent tremors in his hands and fingers. Defendant-Appellee Sun Life Assurance Company of Canada (“Sun Life”) insured a group long-term disability (“LTD”) policy which covered Roehr. Sun Life found Roehr disabled and entitled to benefits for over ten years before it terminated his claim. The district court granted Sun Life’s motion for judgment on the record and the Eighth Circuit reversed the district court’s decision. The court concluded that Sun Life abused its discretion by terminating Roehr’s benefits based substantially on the same records it had before it when it found him continuously disabled for ten years. In other words, the court found that there was no evidence in the record to justify Sun Life’s about-face. The court remanded the matter to the district court with directions to order Sun Life to reinstate Roehr’s benefits.

Roehr had a strong family history of Parkinson’s disease so in 2004 when he started experiencing hand and finger tremors he was quite concerned. He consulted with three neurologists who ruled out Parkinson’s disease. Roehr self-prescribed a Parkinson’s medication called Sinemet because it was somewhat effective in controlling his symptoms. Two of the neurologists recommended against Sinemet but one ultimately agreed it was effective and prescribed it. Roehr stopped working in October 2006 as an anesthesiologist due to “Tremor, Bradykinesia (slow movement), Rigidity, Postural Instability, Decreased Fine Motor Control.” Sun Life approved Roehr’s LTD claim. By 2008, none of the neurologists were able to come to a specific diagnosis related to Roehr’s tremors and over the next ten years Roehr elected to continue his follow-up treatment with his primary care physician. His physician provided Sun Life with updates when requested and Sun Life continued to approve and pay his claim even when some treatment records failed to note an observation of tremors.

Then at the end of 2017, Sun Life retained Dr. Frisso Potts, an independent neurologist, to review Roehr’s file. Dr. Potts reviewed the records and spoke with Roehr’s doctor. He concluded that the medical evidence does not preclude Roehr from returning to his occupation as an anesthesiologist. Sun Life terminated Roehr’s claim and listed seven reasons for its decision, including reasons which had long existed with Roehr’s claim but which Sun Life never made an issue about until it terminated his claim. Sun Life determined Roehr could work as of January 2017 and demanded that Roehr reimburse it for LTD benefits it paid from January through November 2017 in the total amount of $101,333.33.

Roehr appealed Sun Life’s decision and Sun Life had his appeal assigned to a Senior Benefit Consultant (who was not involved in the termination decision) and retained another neurologist, Dr. David Hoenig, to review Roehr’s medical records. Dr. Hoenig acknowledged that Roehr had a movement disorder and recommended an assessment by a neurologist/movement disorder specialist to ascertain any neurologically based functional impairment. Sun Life did not have Roehr evaluated. Instead it upheld its decision claiming “(1) a lack of proof that Roehr’s condition was worsening or permanent; (2) the presence of tremors that seemed mild and controlled by medication; (3) complaints of a “movement disorder” by Roehr’s that only seemed to surface after his benefits were terminated; (4) the possibility that Roehr could be faking or exaggerating tremors; (5) the timing of disability; and (6) Roehr’s failure to see a neurologist since January 2008 and/or completion of evaluations recommended by his former neurologists.”

On the standard of review, the court agreed with the district court that the abuse of discretion review standard applied. It rejected Roehr’s argument that a more relaxed standard of review should apply since Sun Life sought to reduce any potential conflict of interest or bias by consulting with two independent physicians. However, on the merits of the LTD claim, the court sided with Roehr. It found that “Sun Life relied on virtually the same medical records for a decade and has pointed to no information available to it that altered in some significant way its previous decision to pay benefits.” The court also found that Sun Life’s failure to follow the suggestion of its own neurologist and have Roehr complete an independent medical exam was an abuse of discretion. Even though one treatment record noted “no local findings or movement disorder”, his tremors were consistently described as intermittent, and a subsequent record indicated the tremors were present. Lastly, Sun Life never objected to Roehr’s choice to treat with his primary care physician for nearly ten years. Informing Roehr in the final termination letter that this treatment was inappropriate left him with no meaningful opportunity to respond or seek other treatment. Several of Sun Life’s reasons for denial were “nothing more than a sudden change of heart on essentially the same record after almost a decade—and with no notice to Roehr prior to his benefits’ termination.”

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