Doe v. Standard Ins. CoDoe v. Standard Ins. Co (U.S. District Court for the Northern District of Georgia, ERISA Long Term Disability). Plaintiff, a 48-year-old successful obstetrician/gynecologist, sued Defendant insurance company under ERISA for wrongful denial of long term disability benefits. In 1996 Plaintiff underwent open heart surgery to repair a faulty mitral valve.The surgery was generally successful, but during his recuperation the Plaintiff’s family noticed subtle changes in his cognitive abilities (memory, attention, concentration and mood). These problems did not resolve over time. Plaintiff’s doctors advised that he was unable to competently perform his duties as a physician, and he applied for long term disability benefits with Defendant. Defendant paid benefits for four months to allow recuperation from surgery, then unilaterally suspended benefits, refusing to acknowledge the legitimacy or impact of plaintiff’s cognitive problems.Plaintiff, with assistance of counsel, developed extensive expert proof that: (1) he had suffered a fairly common complication of open heart surgery (while on a heart/lung machine, micro-embolic matter can be released into the brain, causing microscopic damage to brain structures); and (2) that this injury disabled Plaintiff from practicing medicine and/or from earning 80% of his pre-disability income. Standard steadfastly denied the claim, relying on their own numerous experts who opined Plaintiff’s situation was medically atypical and/or not disabling. Plaintiff filed suit in federal court under ERISA. Defendant agreed to mediation after Plaintiff prevailed on a motion for partial summary judgment on two issues: (1) Plaintiff was entitled tode novoreview of Defendant’s denial of the claim under ERISA precedent (defeating as a matter of law Defendant’s assertion that their claims denial was entitled to deferential treatment by the Court); and (2) if Plaintiff could prove his disability resulted from physical damage to his brain, Defendant could not limit benefits to 24 months under a “mental disorder” limitation.

As a result of these rulings, Defendant faced exposure for paying $6,000.00 per month until Plaintiff reached age 65, plus interest and attorney fees. The net present value of this exposure exceeded $1,000,000.00. The case settled for on confidential terms after mediation.

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