Legal Summary: Edwards v. Lincoln National Life Insurance Company

2012 WL 1902396, (M.D. Tenn. May 25, 2012)

Lincoln National denied the claim for LTD benefits even though the claimant had been diagnosed with several medical problems and submitted medical records supporting her complaints of pain.  Lincoln National chose to rely on two doctors they hired to review the claimant’s medical records, and then chose to rely on those doctors’ reports to deny the claim.

The claimant suffered from several medical conditions, the most disabling of which cased pain that precluded her from working.  Lincoln National’s first reviewing doctor rejected limitations due to her pain, because it did “not contribute to functional impairment since there is no associated neuromuscular dysfunction.” Edwards v. Lincoln Nat. Life Ins. Co., 2012 WL 1902396, at *8 (M.D. Tenn. May 25, 2012).  The second doctor Lincoln National hired agreed that her conditions caused limitations, but that she could still do full-time sedentary work, based on his review of the records. Id., at 9.

We argued that Lincoln National should not be allowed to rely on those reports over the reports of treating doctors because Lincoln National’s doctors only did a paper review of the records; the insurance company doctors did not examine the claimant, and Lincoln National’s doctors did not even consult with the treating doctors.

The court explained, “Whether a doctor has physically examined the claimant is indeed one factor that we may consider in determining whether a plan administrator acted arbitrarily and capriciously in giving greater weight to the opinion of its consulting physician.” Edwards, 2012 WL 1902396, at *10, quoting from Kalish v. Liberty Mutual, 419 F.3d 501, 508 (6th Cir.2005).

The court went on to explain that, while the Court of Appeals for the Sixth Circuit has found it is not “inherently improper” to rely on a doctor’s opinion who only reviewed a file, but, “the failure to conduct a physical examination … may, in some cases, raise questions about the thoroughness and accuracy of the benefits determination.” Id., quoting from at Calvert v. Firstar Fin., Inc., 409 F.3d 286, 395 (6th Cir.2005).  The court added, “[w]hen a plan administrator’s explanation is based on the work of a doctor in its employ, we must view the explanation with some skepticism.” Edwards, 2012 WL 1902396, at *10, quoting from Kalish, 419 F.3d at 507.  The court also pointed to McDonald v. Western–Southern Life Ins. Co., 347 F.3d 161, 170 (6th Cir.2003) for the proposition that evidence does not support a denial of benefits when only the insurance company’s “physicians, who had not examined [the claimant], disagreed with the treating physicians.”

The court added another reason the insurance company should not just rely on its own hand-picked doctors; “[a] fiduciary must evaluate its expert’s opinion and determine that its expert’s opinion is justified under the circumstances.”  Edwards, 2012 WL 1902396, at *10, quoting from Gregg v. Transportation Workers of America International, 343 F.3d 833, 841 (6th Cir.2003).

The court acknowledged that the United States Supreme Court rejected a general rule that ERISA decisionmakers must give more weight to a treating physician. Edwards, 2012 WL 1902396, at *11, citing to Black & Decker Disability Plan v. Nord, 538 U.S. 822, 834, 123 S.Ct. 1965, 155 L.Ed.2d 1034 (2003). However, the court explained that according to the Supreme Court in Nord, “a consultant engaged by a plan may have an ‘incentive’ to make a finding of ‘not disabled, so a treating physician, in a close case, may favor a finding of disabled[;]’ ” and that “[t]he administrator, however, may not arbitrarily refuse to consider the opinions of treating physicians.”  Edwards, 2012 WL 1902396, at *11, citing to Nord, 538 U.S. at 832 and 834.

In addition to improperly relying on their own doctors who did not examine the claimant, the court next explained that Lincoln National was arbitrary and capricious for requiring the claimant to have objective evidence of the effects of her illness when her illness caused pain, which cannot be objectively measured.  “As many courts have observed, pain often evades detection by objective means.” Edwards, 2012 WL 1902396, at *13, citing to Brooking v. Hartford Life & Accident Ins. Co., 167 Fed. Appx. 544, 549 (6th Cir.2006)  The court also pointed to other cases supporting the same proposition, such as Kosibu v. Merck & Co., 384 F.3d 58, 62 n. 3 (a claim based on fibromyalgia) and Green–Younger, 335 F.3d 99, 108 (2d Cir.2002) (also based on fibromyalgia).

Insurance companies, like Lincoln National in this case, often double-up on the requirement of “objective evidence,” requiring both objective evidence that a person has a condition and then more objective evidence that the condition causes limitations and restrictions that are disabling.  The court in this case rejected such a double requirement for a condition where the disability is caused by pain, which cannot be objectively measured.  The court explained that, in Yeager 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 diagnoses of such a condition is necessary to find a disability from such an illness.” Edwards, 2012 WL 1902396, at *13.

If a person has a medical condition that is known not to allow for objective evidence to confirm the diagnosis, the court held that the claimant satisfied the requirement of showing she had a potentially disabling condition by presenting “corroborative medical evidence from her treating physicians” that is enough under the Yeager case, supra. Edwards, 2012 WL 1902396, at *14.

The court ultimately concluded that because the claimant had a documented condition that caused pain, but could not be measured, and had documented support from her physicians, that “Lincoln National’s rejection of the treating physicians’ opinions on Plaintiff’s ability to work was arbitrary and capricious.” Id, at 14.

The court reversed Lincoln National’s decision to deny our client benefits.