In Mary Beth Tobin v. Hartford Life and Accident Insurance Company, Plaintiff worked in Florida as manager of costuming operations for Disney Worldwide Services. She had been under the care of a physician for fibromyalgia beginning in February 2012. Her last day of work was October 2, 2012. She subsequently moved to Michigan and continued medical treatment with a board-certified family medicine physician.
Plaintiff filed a claim for long-term disability (LTD) benefits, providing Hartford with her medical records, which included the physician’s statement of functionality. Hartford denied her claim and her subsequent administrative appeals, so she filed this ERISA lawsuit in the U.S. District Court for the District Court for the Western District of Michigan.
The Court held in favor of Plaintiff, reversing Hartford’s denial of disability benefits ruling that both Hartford’s first denial and subsequent denial were both arbitrary and capricious. The Court found that Hartford’s doctors who performed file reviews misstated important evidence, did not address the effects of fibromyalgia, and provided no explanation as to why it ignored the functionality assessment of her treating physician.
The Court provided a background of fibromyalgia cases. It noted that, “fibromyalgia, unlike other illnesses, cannot be confirmed or diagnosed by objective medical tests; it is diagnosed “by elimination of other medical conditions which may manifest fibrositis-like symptoms of musculoskeletal pain, stiffness, and fatigue.”
According to Sixth Circuit, when “treating physicians and specialists have diagnosed fibromyalgia, and the medical research indicates that there are a lack of objective tests to prove this condition, it is unreasonable to require objective findings.”
Initial Denial was Arbitrary and Capricious
The Court carefully analyzed the opinions of Hartford’s peer review doctors and found that they overlooked important evidence in the medical file, particularly the treating physician’s functionality assessment. The reviewers also ignored the fact that there is no objective evidence to prove a diagnosis of fibromyalgia, and commented that the lack of such evidence was one reason for their conclusions that Plaintiff was able to perform her job duties.
The Court found the reasoning of Hartford was flawed and ruled that Hartford’s first denial of benefits was arbitrary and capricious.
Final Denial was Arbitrary and Capricious
Plaintiff filed an administrative appeal after the first denial. Hartford found new reviewing doctors. The Court found Hartford’s reliance on these reports to also be arbitrary and capricious when the reviewing physicians:
- Failed to address the effect of fibromyalgia on Plaintiff’s capabilities.
- Misstated important medical evidence in Plaintiff’s file.
- Noted there were no objective medical evidence in the file to substantiate a diagnosis of fibromyalgia as one reason Plaintiff should be denied benefits.
- Failed to inform Plaintiff of what exact objective evidence it was looking for and give her an opportunity to provide it.
- Completely disregarded the treating physician’s Statement of Functionality.
- Based on all of the evidence, the Court reversed Hartford’s decision denying Plaintiff long-term disability benefits.
This case was not handled by our office, but we thought it might be helpful to those who are battling with their insurance company over their disability claims based on a fibromyalgia diagnosis. We are committed to our fibromyalgia clients and recognize the fight that generally awaits them in pursing their claims. Click HERE for more information on Dell & Schaefer’s experience helping disability insurance claimants diagnosed with fibromyalgia. If you have been diagnosed with fibromyalgia, or have any questions about any disability claim issue, you can contact our disability attorneys at Dell & Schaefer for help. We always offer a free consultation.