Case Story: Our Client v. Lincoln National Life Insurance Company
Our client worked as a senior payroll specialist at Alive Hospice. Their job required them to sit at a computer and perform data entry for most of the day; they submitted a claim for long term disability benefits, asserting that they were totally disabled due to chronic pain in most of their body that made them unable to stand, sit, or focus. Id.
our client was evaluated and treated by multiple physicians for various ailments, such as back and neck pain, rashes, carpal tunnel syndrome, obesity, gastrointestinal distress, and chest pain. Id. In the spring of 2005, they had knee replacement surgery, and soon after that, they complained of pain and lack of energy. Id. at *2. Dr. Sally Burbank, their primary care physician, noted that our client had experienced significant weight gain, and Dr. Houston, our client’s rheumatologist, tested them for lupus, an autoimmune disease. Id. Dr. Houston ruled out lupus as a source of our client’s pain and fatigue, and he noted that their delayed recovery from knee replacement surgery may have contributed to their pain and depression. Id.
On December 7, 2009, Dr. Vaughn Allen examined our client and noted that they had long term chronic pain, and in May 2010, Dr. Allen examined them again for complaints of constant numbness and tingling in their arms. Id. at *5. The chief complaint listed in our client’s application for long term disability benefits was fibromyalgia, a syndrome causing widespread pain and fatigue. Id. at *6, *8. Lincoln National denied our client’s application for long term benefits twice, based on the opinions of physicians hired by Lincoln National who did not examine our client. Id. at *7-*9. Instead, they reviewed their file and found that they were capable of doing their sedentary job. Id.
Insurance companies often deny claims of people disabled by fibromyalgia, either requiring objective tests beyond what is used by doctors to diagnose the condition, or by requiring objective testing of the pain and fatigue caused by the condition, which is impossible to prove. In this case, Lincoln National did just that, and insisted on medical tests to show our client’s fibromyalgia. Because we believed Lincoln National was wrong, and had not followed the law, we sued the insurance company under ERISA on behalf of our client. Id. at *1.
We explained that courts had made it clear that insurance companies could not require objective medical evidence of the condition; rather, “as many courts have observed, pain often evades detection by objective means.” Id. at *13 (citing Brooking v. Hartford Life & Accident Ins. Co., 167 Fed. Appx. 544, 549 (6th Cir. 2006); accord Mitchell v. Eastman Kodak, 113 F.3d 433, 442-43 (3rd Cir. 1997)(Chronic Pain Syndrome); see also Kosibu v. Merck & Co., 384 F.3d 58, 62 n.3 (Fibromyalgia); Green-Younger, 335 F.3d 99, 108 (2d Cir. 2002)(Fibromyalgia)). “In Yearger v. Reliance Standard Life Ins. Co., 88 F.3d 376, 381-82 (6th Cir. 1996), the Sixth Circuit held that only medical evidence of a diagnosis of such a condition is necessary to find a disability from such an illness.” Id. at *13 (emphasis added).
The court acknowledged that law and explained it should do two things with regard to finding disability based on fibromyalgia: first, it had to determine from the record that a diagnosis of fibromyalgia had been made. Id. Secondly, it had to focus on the objective evidence, or symptoms that could be observed. Id. at *14. “[O]bjective evidence of disability due to fibromyalgia can be furnished by the claimant…the physical limitations imposed by the symptoms of such an illness do lend themselves to objective analysis.” Id. at *14 (citing Huffaker v. Metropolitan Life Ins. Co., 271 Fed. Appx. 493, 500 (6th Cir. 2008)(citing Boardman v. Prudential Ins. Co., 337 F.3d 9, 16-17 n.5 (1st Cir. 2003)).
We also argued, and the court agreed with us, that Lincoln National could not arbitrarily refuse to consider the opinions of our client’s treating physicians. Id. at *11 (citing Black & Decker Disability Plan v. Nord, 538 U.S. 822 at 834). Because medical tests could not objectively detect fibromyalgia, the treating physicians’ corroborating medical evidence was key, since they could see our client’s symptoms. Id. at *13 (citing Yearger v. Reliance Standard Life Ins. Co., 88 F.3d 376, 381-82)(6th Cir. 1996)(holding that only medical evidence of a diagnosis of a condition such as fibromyalgia is necessary to find disability from such an illness)). The court ultimately held that our client’s fibromyalgia, along with their other documented sources of pain, supported their physicians’ assessment of long term disability and that Lincoln National’s rejection of their treating physicians’ opinions was arbitrary and capricious. Id. at *14.