A Tennessee Plaintiff filed an ERISA lawsuit regarding the denial of her short term disability and long term disability benefits, contending that 1) she was disabled under the terms of the plan; 2) that United of Omaha Life’s reliance upon the opinions of medical experts who did not physically examine her was inadequate to provide a reasoned explanation for its decision to deny benefits; and 3) that the plan’s self-reported symptoms provision provides for disability payments for up to 2 years.
In this case, the terms of Plan delegated to United of Omaha Life full authority and discretion to make eligibility determinations for benefits and to interpret the terms of the Plan, for both short term and long term disability. Because of this, the Tennessee court applied the arbitrary and capricious standard of review. Accordingly, the court was charged only with the task of deciding whether United of Omaha Life’s decision to deny short term and long term benefits to the Plaintiff was based on a reasonable interpretation of the Plan.
Was Ms. Holden disabled under the terms of the Disability Plan?
In order to satisfy the definition of disability under the terms of United of Omaha Disability Plan, the Plaintiff, Ms. Holden, was required to establish that, as a result of injury of sickness, she has a "significant change in Your mental or physical capacity and You are: a) prevented from performing at least one of the Material Duties of Your Regular Occupation on a part-time or full-time basis; and b) unable to generate Current Earnings which exceed 99% of Your Basic Monthly Earnings due to that same Injury or Sickness. After a Monthly Benefit has been paid for 2 years, Disability and Disabled mean You are unable to perform all of the Material Duties of any Gainful Occupation." The Plan further stated that to receive a monthly benefit, acceptable proof of loss must be provided.
Disability Claim Based on Fibromyalgia, Lupus and Migraines
Ms. Holden had a long documented medical history of accelerated chest pain syndrome, cardiac catheterization with normal findings, noted lupus erythematosus, migraine headaches, noted fibromyalgia, small L1-2 disc protrusion without impingement and minimal L4-5 facet joint degenerative changes, with complaints of symptoms such as heart palpitations, muscle and joint pain, fatigue, arm pain, ankle swelling, syncope, near-syncope, and difficulty with prolonged sitting, rising and lifting.
When Ms. Holden filed her initial claim for short term disability benefits in February 2009, she was treating with her primary care physician, a nurse practitioner, rheumatologist and a cardiologist, with complaints of edema, palpitations, arm pain, nausea and rear syncopal feeling. In May, Ms. Holden was awarded short term disability benefits up to 4/21/2009 as United of Omaha Life’s Nurse Case Manager found that the medical records were sufficient to support restrictions and limitations up to the 4/21/09 office visit with the cardiologist while she was being evaluated for angina and her medications were being adjusted. However, her cardiac conditioned had stabilized as she was not required to follow up with the cardiologist for 6 months, and her main complaints at this point were related to fibromyalgia and lupus.
It should be noted that although fibromyalgia is characterized by subjective complaints of pain and fatigue, there are widely accepted diagnostic tests which are used to objectively establish a diagnosis of fibromyalgia. These tests involve identifying specific "tender points" on the patient. If the patient possesses a minimum of 11 out of the 18 defined tender points, they are eligible for a diagnosis of fibromyalgia. In this case, Ms. Holden never met the criteria for a diagnosis of fibromyalgia and laboratory tests did not confirm a diagnosis of lupus, which also produces subjective symptoms such as generalized pain and fatigue.
Additional medical records were requested and provided to United of Omaha Life, and a second review of the medical file concluded that continued restrictions and limitations were not supported beyond 4/21/09 because Ms. Holden had not demonstrated the she was unable to perform her job duties which were classified as sedentary. United of Omaha Life denied further disability benefits and Ms. Holden appealed.
Ms. Holden continued to treat with her medical providers and submitted her appeal to United of Omaha Life in December 2009 and in January 2010, a third review of the medical file was conducted and determined that the medical information lacked objective physical and diagnostic findings which supported restrictions and limitations that would preclude Ms. Holden from performing the material duties of her regular sedentary job. The denial letter included a detailed summary of the review of the medical records that was performed.
Ms. Holden continued to treat for her generalized symptoms, but physical examinations and diagnostic testing resulted with normal findings.
In June 2010, Ms. Holden applied for long term disability benefits due to pain, inability to get out of bed and inability to drive. A physician’s statement indicated she could not work because of fibromyalgia, osteoarthritis, lupus and migraine headaches. United of Omaha Life had their Senior Vice President and Medical Director, Dr. Reeder, review Ms. Holden’s medical record. Dr. Reeder concluded that Ms. Holden did not meet the accepted criteria for a diagnosis of fibromyalgia or rheumatoid arthritis, and that there was no medical evidence to support functional loss or that Ms. Holden was incapable of working in a sedentary occupation. In December 2010, Ms. Holden’s long term disability benefits were denied and she appealed.
During the appeal, Ms. Holden underwent an arthroscopy surgery, which was tolerated well, and a follow up with her rheumatologist indicated her FMS score was 5/18 with no weakness.
United of Omaha Life retained a rheumatologist, Dr. Peck, to perform a review of Ms. Holden’s medical records. Dr. Peck noted that Ms. Holden’s records indicated that she did not fulfill the criteria for fibromyalgia, and lab results indicated a false positive ANA with no evidence of lupus or other connective tissue disease. Dr. Peck opined that the restrictions and limitations provided by the treating physicians were not supported with medical evidence of impairment, even in the doctors’ own notes, and that Ms. Holden is capable of light work on a full time basis. The restriction to light work results from the facts that she has internal derangements of her knees, lumbar spondylosis and myofascial pain syndrome. Based on Dr. Peck’s review, United of Omaha Life upheld its denial of long term disability benefits.
While Ms. Holden claimed that she was disabled under the terms of the Plan, she conceded that she was not able to clearly prove through her records that she was disabled, but that her claim was entirely dependent on subjective evidence of her disability. She further argued that the Self-Reported Symptoms provision of the plan, in and of itself, was enough to prove that her self-reported symptoms were sufficient evidence of disability. However, United of Omaha Life responded that while self-reported symptoms may be used as evidence of an illness, Ms. Holden still must provide sufficient objective evidence of disability from such an illness. The Court in this case recognized that, while it is unreasonable to require objective evidence of a subjective illness, objective evidence of disability may be required, even when the alleged disability stems from fibromyalgia, as long as the Plan administrator notifies the claimant that it requires additional objective evidence of the disability.
In this case, United of Omaha Life repeatedly requested, from both Ms. Holden and her physicians, objective medical evidence to support her claim of disability and inability to perform her job. Ms. Holden and her physicians failed to submit sufficient objective evidence and several of her treating physicians actually indicated to United of Omaha Life that she was not restricted to perform sedentary work.
Was United of Omaha Life’s reliance upon the opinions of medical doctors that never examiner the claimant Sufficient to support a disability denial?
Ms. Holden further alleges that United of Omaha Life acted unreasonably by basing its decision to deny benefits on the opinions of "non-examining file reviewers", rather than having a physical examination performed. The court found that there was no Plan language which barred a medical file review in lieu of a physical examination.
The independent medical reviewers retained by United of Omaha Life were of the appropriate medical specialties and it is apparent in their reports that they greatly considered the treatment, assessments and opinions of Ms. Holden’s treating physicians. The independent reviewers also provided the treating physicians with the opportunity to respond and provide comment on the reports. Dr. Reeder noted that Ms. Holden’s rheumatologist refused to respond and suggested she be referred for a functional capacity examination. Her cardiologist advised that her chest pain was non-cardiac in nature and that she did not have any work restrictions, including driving. Dr. Reeder wrote to Ms. Holden’s nurse practitioner citing his review of the medical records, and indicating that, in his opinion, the records did not support restrictions and limitations which precluded Ms. Holden from performing her sedentary occupation. Dr. Reeder requested that any information with physical exam or diagnostic test findings, or other objective evidence to support work restrictions and limitations be submitted. The nurse practitioner’s office informed United of Omaha Life that she would not be responding because she agreed with Dr. Reeder’s letter/assessment. Other additional records submitted by Ms. Holden’s treating physicians noted that she did not have any work restrictions or limitations.
Because the independent medical reviewers actually gave great weight to the medical record, and went so far as to contact the treating physicians, by telephone and by letter, to discuss Ms. Holden’s case, under the arbitrary and capricious standard of review, United of Omaha Life did not act unreasonably by relying on their opinions as a basis for the decision to deny Ms. Holden’s benefits.
Outcome of the ERISA Lawsuit Against United of Omaha
The Tennessee Court found that United of Omaha Life did not act unreasonably and its decision to deny Ms. Holden’s short term and long term disability benefits was not arbitrary and capricious. The court granted United of Omaha Life’s motion for judgment on the record and denied Ms. Holden’s motion for judgment.
Ms. Holden’s claim of disability was based solely on subjective complaints of pain and fatigue. All of the objective measures, even for such subjective syndromes such as fibromyalgia and lupus, had negative results for Ms. Holden and no firm diagnosis could be established which would support her claim for disability. Even Ms. Holden’s treating physicians did not support her in her claim for disability. Our law firm did not handle this claim.
Ms. Holden and her disability lawyers incorrectly relied on a self-reported symptoms policy provision as a means to prove her disability claim, when the purpose of that provision was to acknowledge that some conditions are diagnosed based on subjective symptoms, and to establish that in such an instance, the disability benefits would be limited to 24 months. This case is another example of how important it is to have strong physician support in order to obtain of approval of long term disability benefits.
If you have a disability insurance claim and would like to know your legal options, contact Attorneys Dell & Schaefer for a free consultation.