Nationwide Long Term Disability Attorneys
Below are some descriptions of cases, sorted by insurance company, that have been resolved successfully on behalf of our clients. These descriptions can give you a general idea of the types of cases and the rulings against particular insurance companies. For more information about these matters, get in touch with our lawyers at the office of Alan C. Olson & Associates by contacting us through this website or call our firm at 888-843-1261 or 262-785-9606.
UNUM
UNUM held “arbitrary and capricious” for ignoring claimant’s subjective evidence of her pain and the opinions of her treating doctors
Our client, “Pamela” was employed full time as an office assistant. She was 50 years old at the time. Pamela’s responsibilities included supporting the secretarial activities of her department. Her job required her to sit for long periods of time working on a personal computer. In addition, she was required to work 40 hours a week.
Pamela was injured in a car accident. She filed a claim for long-term disability benefits under a disability insurance policy issued by UNUM to the employer and its employees. In the Attending Physician Statement that Pamela submitted with her claim, her doctor diagnosed Pamela with neck and upper back pain and indicated that Pamela was unable to work. He also indicated that Pamela was restricted from lifting, pushing, pulling and keyboarding on a computer. Pamela supported her claim for disability with the results of her MRI, the results of an occupational assessment test, the opinions of her treating physicians and her own reports.
The Court found that Pamela’s medical records “painstakingly documented” the many efforts she made over the course of a year to treat her pain: medication, physical therapy, chiropractic care, steroids and ergonomic modifications. None were successful and all the reviewing doctors agreed that surgery was not an option for her. Her pain was aggravated while using a keyboard because of the position in which she was required to hold her head. By the end of the workday, she had “severe posterior headaches.”
In concluding that Pamela could perform her job, neither UNUM nor its doctors identified any problems with the reports of Pamela or her treating physicians or identified any other evidence that Pamela should provide to support her claim. Instead, they simply said that the symptoms Pamela reported were greater than what the objective evidence would suggest.
Pamela and her doctors explained that sitting in a chair and using a keyboard caused her “severe” pain by the end of the day. Although Unum’s doctor wrote that Pamela could deal with her pain by “switch[ing]positions” and “stretch[ing] periodically,” neither he nor UNUM explained why that would be an adequate accommodation. Even more problematic, this view ignored Pamela’s year-long attempt to find ways to treat and accommodate her pain, including physical therapy, “an ergonomic evaluation” and “strategies to provide maximal support to Pamela in the workplace.”
In rejecting Pamela’s claim, UNUM simply disregarded all the unsuccessful efforts Pamela made to treat her pain and keep working. It is not reasonable to assume without explanation that simple stretching would be sufficient to permit Pamela to work when much more aggressive measures failed to provide her with relief.
The Court found other problems with UNUM’s decision as well. First, UNUM ignored the vocational evaluation concluding that Pamela was unable to perform even sedentary work, despite a “good effort” she put forward during the evaluation.
Finally, the determination by UNUM that Pamela was not disabled after a specific date “cannot be squared” said the Court, with its consultant’s decision that she was disabled up to that specific date, even though the evidence to support both claims was exactly the same. “This puzzling disparity is enough by itself to conclude that UNUM’s decision was arbitrary and capricious”, the Court held.
The Court agreed with us that UNUM’s decision terminating benefits was arbitrary and capricious because the administrator had relied on the opinion of a doctor who did not explain the basis for his opinion or why it differed from the opinions of Pamela’s treating physicians. UNUM’s decision was arbitrary and capricious because it failed to provide a “reasoned explanation” that considered “the relevant factors that encompass the important aspects of the problem.”
Court found Unum had failed to set forth the specific reasons for denying disability benefits, written in a manner calculated to be understood by the participant.
In another case involving Unum, our client, “Jim”, worked at Trek Bicycle as a bike frame finisher. The job required him to stand all day, sanding down bicycle frames. He did minimal lifting but “a lot of repetitive motion.” Jim was in a rollover car accident and sustained a cervical disc protrusion in his neck at C5-6 and suffered chronic pain in his neck and back.
Jim’s application for long term benefits was supported by a report from his physician saying that Jim described “severe pain across the lower back that is made worse with activity including any bending, twisting or prolonged standing.” He noted that “a recent MRI scan did show evidence of a disc protrusion in the cervical spine, and broad disc bulging in the lumbar spine,” and restricted Jim to “sedentary type-work with no bending, twisting or pushing or pulling.”
Unum’s doctor reviewed Jim’s records and issued a report in which he found that “[t]he [restrictions and limitations] involving the claimant’s back and neck conditions appear overly restrictive” but did not say anything about Jim’s ability to stand, use his hands repetitively or perform other occupational duties. Unum also required Jim to undergo a functional capacity evaluation. Jim was found to have a maximum capacity for standing “occasionally” in the course of a regular 8-hour workday, that is, up to 1/3 of the day.
Unum nevertheless affirmed its earlier decision to discontinue long-term benefits to Jim on the ground that the functional capacity evaluation and the reviews by its consulting physicians showed that Jim was capable of full-time work in his own occupation.
The Court held that, “ERISA requires employee benefit plans that deny disability benefits to ‘set[]forth the specific reasons for such denial, written in a manner calculated to be understood by the participant.'” The Court reasoned, “the fact that Unum and not [Jim] was responsible for producing the functional capacity evaluation does not relieve Unum of the need to consider the results of that evaluation and to explain to [Jim] why it chose not to give any weight to the results. . . . Unum must reconsider. . . [the] discrepancy between the evaluation results and the opinions of its consulting physicians.” This decision demonstrates that a carrier that fails to explain why it discounted evidence of our client’s disability will lose in court.
Unum may not deny benefits because symptoms are self-reported
In appealing Unum’s denial of LTD benefits to our client, “SW”, we challenged the application of the self-reported symptoms limitation to her claim. Unum’s summary plan description (“SPD”) made no mention of the self-reported symptoms limitation. Unum’s approval letter included language from the plan on what was considered a disability but did not mention the self-reported symptoms limitation. In its letter of explanation, Unum did not dispute SW’s diagnosis of fibromyalgia but instead emphasized that her pain, being the primary symptom associated with her fibromyalgia, was based on self-report. As such, benefits were limited to twenty-four months by the self-reported symptoms limitation.
We then filed the lawsuit that was decided by the Seventh Circuit Court of Appeals (which decides long-term disability benefits cases from Wisconsin, Indiana and Illinois). The court said that, “to determine whether the self-reported symptoms limitation applies here, we begin with the language of the plan, which limits payment for “[d]isabilities, due to sickness or injury, which are primarily based on self-reported symptoms,” but the parties disagree as to what this clause means. Unum alleged that the focus was on whether the limitation on function is primarily based on self-reported symptoms. We argued that the focus must be on whether the diagnosis of the disease itself is primarily based on self-reported symptoms.
The court refused to read the clause literally as Unum proposed (the plural self-reported systems clause modifies the plural “Disabilities” rather than the singular “illness or injury,” suggesting that if the inability to perform work is self-reported, the limitation applies), when the clause is considered in context and in light of actual application, the only viable conclusion is that the self-reported symptoms limitation applies to disabling illnesses or injuries that are diagnosed primarily based on self-reported symptoms rather than to all illnesses or injuries for which the disabling symptoms are self-reported.
The court held that the contrary interpretation advanced by Unum would sweep within the limitation virtually all diseases, leaving only a small subset for coverage. For most illnesses or injuries, the disabling aspect is not the disease itself, but the pain, weakness, or fatigue caused by that illness or injury. Even diseases that are extremely likely to cause an inability to work, such as stage IV cancer or advanced heart disease, are disabling because of the pain, weakness or fatigue. Under Unum’s interpretation, however, the court reasoned, those diseases would fall within the twenty-four-month limitation because pain, weakness and fatigue are self-reported symptoms that are difficult if not impossible to verify using objective medical evidence.
In fact, at oral argument, Unum conceded that under its interpretation the provision would limit coverage for all conditions in which the disabling symptom is pain. Unum even maintained this was true regardless of the etiology of the pain, so that even if the underlying condition were highly likely to cause pain, the limitation would apply because the pain itself is self-reported and not verifiable.
The court rejected Unum’s “bold assertion”, finding no indication that Unum actually applied or proposed to apply this limitation to disabilities based on diagnoses that can be objectively verified by clinical tests, procedures, and clinical examinations. The court refused to countenance a reading that would allow Unum arbitrarily to disallow any illness or injury that it preferred not to cover while not making that explicit in its SPD.
As to the remaining question of whether the diagnosis of disabling fibromyalgia in the present case was based primarily on our client’s self-reported symptoms or on objective medical evidence, she was diagnosed following the 18-point “trigger test”. The court found that the trigger test can “more or less objectively” establish the disease where the findings of the test are consistent with fibromyalgia. The trigger test “qualifies as a clinical examination standardly accepted in the practice of medicine.”
Ultimately, the court agreed with our client’s treating rheumatologist who concluded that “[d]espite interventions by neurology, psychiatry, psychology, neuropsychology, orthopedics, physiatry, integrative medicine, [and a] pain program with multiple interventions from these services, [SW] remains unable to work.” Accordingly, Unum was instructed to reinstate our client’s benefits retroactive 4 years and awarded the costs our firm incurred in bringing suit.
PRUDENTIAL
The Court of Appeals held that Prudential must weigh all of the medical evidence, including any of the evidence favoring the claimant such as affidavits
Our client, “Paul”, received a decision from the Seventh Circuit Court of Appeals in his favor. Paul enjoys disability insurance as a fringe benefit of his job. He stopped working because of a hernia and back pain. The hernia was repaired surgically, but Paul did not return to work. After a psychiatrist diagnosed Paul with dysthymia and major depression, Prudential started sending him long-term disability payments. But “long-term” means two years, the Plan’s limit when inability to work is caused even in part by a mental illness (which the policy defines to include depression). Prudential ended the disability benefits, citing the two-year cap. After exhausting his administrative remedies, we filed suit on Paul’s behalf.
After filing suit, we had proposed to take discovery in order to generate evidence about Paul’s medical and mental conditions, and the extent (if any) to which his mental condition affects his ability to work. Prudential opposed all discovery, contending that the suit should be resolved on the administrative record. The district court concluded that no discovery at all is appropriate and barred all discovery on medical questions. We then asked some of Paul’s physicians to provide affidavits describing his spine condition and prognosis, and we tendered these to the judge-who struck them from the record, writing:
The submission of materials outside of the administrative record contradicts the scope and intent of the Court’s protective order. While that order was directed towards future discovery, [Paul] cannot circumvent the force of the protective order by surreptitiously filing information outside of the administrative record in support of his motion papers.
Having barred us from offering any evidence, the judge then granted summary judgment to Prudential, relying on the two-year cap and the fact that the administrative record contains two medical evaluations implying that Paul was able to work. The judge did not mention the contrary evidence in the administrative record.
The Court of Appeals criticized the district court, holding that, “we cannot imagine any justification for refusing to admit evidence that one party has procured at its own expense, such as the medical affidavits that [Paul] tendered. Tellingly, the district judge did not cite authority for throwing out the affidavits, and Prudential’s brief does not supply any.”
This case makes clear the importance of submitting evidence of disability in the form of affidavits and to request the court to allow discovery for purposes of challenging the opinions of the insurance carrier’s reviewing doctors. If the district court will not listen to reason, the Court of Appeals may come to the rescue, as it did in this case.
MetLife
MetLife Loses LTD Case in California Court
Our client, “John”, won his LTD claim against MetLife in a California court.
A. John’s Employment
John’s job duties included evaluating and understanding a variety of patents and technologies in mining and intellectual property. His position required “an advanced/graduate degree in a science or engineering discipline, particularly in the information and communication technology areas. John’s job was sedentary-to-light; it required sitting at a workstation doing computer work and reading.
John fell backward onto his buttocks and back. Thereafter, he complained of back pain, intermittent leg numbness and pain, pain and/or numbness in other areas, headaches, blurred vision, and dizziness. John continued to work for several months, but only for partial days and weeks. He then stopped working completely, asserting that his back pain had become intolerable and filed a claim for LTD benefits under the Plan. He claimed that he was unable to sit, walk, or stand for more than three to five hours in the workday.
B. MetLife Used Wrong Claim File to Deny John’s Benefits.
MetLife sent John a denial letter stating that he had failed to prove entitlement to benefits under “the United Airlines plan.” According to the letter, MetLife attempted to call John but his telephone number was “disconnected”. John wrote back asking whether the letter had been sent to him in error, since he did not work for United Airlines and his telephone had not been disconnected. John included his telephone number in the letter, stating that it had been prepaid though the year.
MetLife sent John a second denial letter again asserting that John’s telephone number had been disconnected, and that it had been unable to reach John’s “doctor.” The letter stated that “[s]ince we have not received the requested information, you’re [sic] Long-Term Disability benefits have been denied.” MetLife then sent John a third denial letter, this time, misstating John’s occupation.
C. MetLife Improperly Ignored Social Security Decision
The Court held that the Social Security decisions would be persuasive evidence that John was disabled as required by the Plan, because, the Social Security standards are more stringent in this instance. “Moreover, the Supreme Court has found questionable MetLife’s conduct in requiring a claimant to argue to the Social Security Administration that she could do no work, and then ignoring the agency’s finding in concluding that the claimant in fact could do sedentary work”, said the Court.
D. Proof Of Disability
The Court found it “undisputed” that John fell in the manner claimed, and that he suffered disc desiccation, broad-based disc bulge, and disc protrusion at L4-5. Five different physicians that either treated or examined John opined that he had significant limitations on sitting and standing and “[c]hronic disabling lumbar pain of probably diskogenic etiology”.
The Court said that it was, “at a loss to imagine how [John] could perform his own occupation, which undisputedly consisted primarily of sitting in front of a computer, if he could not sit.” It was also found significant that none of the physicians expressed doubts as to the degree of pain reported by John; there was no suggestion that he was malingering.
E. MetLife Relied On Mere Paper Review
The only doctors who suggested that John did not suffer disabling pain were the two doctors hired by MetLife, Drs. Smith and Turok. Neither Dr. Smith nor Dr. Turok ever met or examined John; thus neither had any opportunity to assess his credibility. The Court concluded that under these circumstances, it was an abuse of discretion for MetLife to reject John’s subjective pain complaints and, based upon that rejection, to discount the medical opinions that credited those complaints. While a plan administrator is not required to subject the claimant to an in-person medical examination, in performing the abuse of discretion analysis the Court may consider the fact that the administrator relied upon a paper examination.
MetLife’s hired doctors focused on John’s “refusal” of a lumbar epidural steroid injection and/or surgery. However, as noted by the Court, MetLife did not point to any evidence that agreeing to a steroid injection and/or surgery were the only reasonable medical decisions that John could make.
F. MetLife Abused Its Discretion
In considering the administrative record as a whole, including the consistency of John’s pain complaints from the time of his fall onward, the MRI demonstrating a disc injury, the opinions of five different doctors who treated or examined John, the absence of any evidence of malingering, the fact that Drs. Smith and Turok did not examine John, and the fact that MetLife has an inherent conflict of interest because it both administers and funds the Plan, the Court concluded that, “MetLife abused its discretion in denying [John’s] claim for benefits.”
Unfortunately, abuse of discretion by MetLife in denying LTD benefits has been documented in numerous court decisions. MetLife’s abusive practices are in my opinion systemic and nationwide.
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