Case Story: Our Client v. Life Insurance Company of North America

United States District Court for the Eastern District of Tennessee (2015).

Our client worked as a project administrator for a large engineering and construction company until her fibromyalgia, and its accompanying symptoms disabled her. LINA originally agreed to pay benefits under the LTD policy provided by our client’s employer.  After agreeing she was disabled for about 18 months, LINA terminated her benefits, claiming that she did not have such an impairment that would render her unable to work. We appealed this termination, and LINA once again denied her benefits. From there, we sued.

Two rheumatologists and the claimant’s primary care physician personally examined her and determined that she had fibromyalgia and could not return to work. LINA originally approved her long term disability claim on this basis, but when LINA learned that the claimant was achieving slight improvement, it terminated her benefits. LINA construed her doctor’s noted minor improvements as an indication that she was now able to work again.

We appealed this termination to LINA and submitted an additional opinion from our client’s doctor setting out her limitations, which showed she did not have the physical abilities necessary to perform her profession. LINA hired a rheumatologist to evaluate the claim based only on her medical file—not on any personal examination of our client. The doctor hired by LINA concluded that the medical records gave no indications from a “rheumatology standpoint” that our client had any such restrictions or limitations that would disable her from working. Based on this opinion, LINA affirmed its denial of our client’s claim. We then sued.

Because the policy gave discretion to the administrator in construing the plan and determining eligibility, the court reviewed LINA’s decision under an arbitrary and capricious standard. This standard looks at whether the administrator’s determination and decision-making process was reasonable, given the information in front of the administrator at the time of its determination. The court first looked at the fact that LINA had the option to submit the claimant to an in-person physical independent medical examination, but instead relied only on a medical file review by their doctor. Although this choice is not determinative of whether an administrator acted arbitrarily and capriciously, it weighed against LINA—especially in light of the nature of fibromyalgia as a condition that requires medical evaluation of subjective symptoms.

Additionally, LINA’s hired rheumatologist merely gave a conclusory rejection of the treating doctor’s findings. The rheumatologist gave no reasoning for why our client’s medical record does not support any restrictions or limitations. Instead, the court found that the rheumatologist was “implicitly making a credibility determination about [the claimant’s] subjective symptoms and their effect on her ability to perform various mental and physical tasks.”

All in all, the court agreed with us that LINA was arbitrary and capricious in its determination that our client was not disabled. The court articulated several factors for this finding:

(1) [LINA’s doctor] was a non-treating reviewer dealing with the inherently subjective matter of fibromyalgia symptoms, which require credibility determinations; (2) [LINA’s doctor’s] opinion lacked substantive analysis; (3) [LINA’s doctor’s] conclusion that no restrictions and limitations whatsoever should apply was grossly at odds with treatment records and [the treating doctor’s] opinion; and (4) LINA never substantively addressed the SSDI award despite having required [the claimant] to apply for SSDI benefits and having acknowledged the award.

Because the court concluded that LINA was arbitrary and capricious in its determination, the court remanded the decision back to LINA for a proper review of her claim. This allowed us to continue fighting for our client’s benefits.

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