by Cody AllisonIs Your Disability Plan Governed by ERISA?
If you believe you have been wrongfully denied your ERISA, or non-ERISA, long-term disability benefits, give us a call for a free lawyer consultation. You can reach Cody Allison & Associates, PLLC at (615) 234-6000, or toll free (844) LTD-CODY. We are based in Nashville, Tennessee; however, we represent clients in many states (TN, KY, GA, AL, MS, AR, NC, SC, FL, MI, OH, MO, LA, VA, WV, just to name a few). We will be happy to talk to you no matter where you live. You can also e-mail our office at cody@codyallison.com. Put our experience to work for you. For more information go to www.LTDanswers.com
There are many types of disability insurance plans out there, and many employers provide these types of plans for their employees. However, not all of these plans are governed by the Employee Retirement Income Security Act, or ERISA. How do you tell if your plan is or is not governed by ERISA?
ERISA was a law enacted in 1974 and applies to private long-term and short-term disability insurance provided by an employer. It is designed to protect workers with these plans. ERISA sets up a framework for how disability claims are processed, the timeline for processing these claims, and what the policyholder’s rights are in the event of a denial of the insurance proceeds under these plans. You, as an employee, should receive a copy of your policy which provides the material provisions of your employer’s plan.
Most private companies which provide short- and long-term disability coverage will have plans that are governed by ERISA. However, your plan may not be covered if the employer makes no contributions to the plan and if participation in it is completely voluntary. Some employers may even allow these voluntary payments to be taken out of the paycheck automatically and allow the insurer to advertise the plan at the workplace, and still be be involved in the actual plan itself, which would mean that the plan is not covered by ERISA.
Also, certain types of employers, even if they provide the plan, may not be covered by ERISA. These may include federal, state and local government employers and church employers. Be aware that if your employer contracts to work for governmental entities, even though your employer is not a governmental entity, this may mean your plan is not covered by ERISA. However, some governmental employers may be governed by laws that are similar to ERISA but designed for governmental entities.
If you have questions about whether or not your disability plan is covered by ERISA, call us. We are here to help.
by Cody AllisonChanges in the Department of Labor’s Disability Claims Procedure Regulations
If you believe you have been wrongfully denied your ERISA, or non-ERISA, long-term disability benefits, give us a call for a free lawyer consultation. You can reach Cody Allison & Associates, PLLC at (615) 234-6000, or toll free (844) LTD-CODY. We are based in Nashville, Tennessee; however, we represent clients in many states (TN, KY, GA, AL, MS, AR, NC, SC, FL, MI, OH, MO, LA, VA, WV, just to name a few). We will be happy to talk to you no matter where you live. You can also e-mail our office at cody@codyallison.com. Put our experience to work for you. For more information go to www.LTDanswers.com
On December 19, 2016, the Secretary of Labor (DOL) announced amended final disability claims procedure regulations, effective April 1, 2018, for ERISA-covered plans. 29 C.F.R. § 2560.503-1. The DOL had set an original implementing date of January 1, 2018, but in December of 2017, DOL delayed the implementing date to April 1, 2018. The amended regulations clarify existing regulations and impose new standards on ERISA fiduciaries to assure fairness when evaluating disability claims.
The amended DOL regulations contain four significant changes, among several others, regarding the adjudication of the disability claims under ERISA.
- Impartiality. Claims and appeals must be determined in a manner to assure independence and impartiality of the persons making the benefit decisions and their consultants.
- New Evidence. On appeal of an adverse benefit determination, claimants must be given timely notice of any new evidence “considered, relied upon, or generated” by the entity making the benefit determination and an opportunity to respond before a final determination is rendered.
- Thorough Discussion of Grounds for Denying Claim. Adverse-benefit determinations must contain a substantive discussion for a decision, including the basis for disagreeing with the views of health care professionals, vocational professionals, and with disability benefit determinations by the Social Security Administration.
- Limitations Periods. Adverse-benefit determination letters must inform the claimant of the limitation periods on filing administrative appeals, and in the case of an adverse determination on review, of the calendar date on which any applicable contractual limitations period for filing a lawsuit expires.
Point number two—New Evidence—was perhaps the most controversial amendment to the regulations, at least, from the perspective of insurance companies. The amended regulations do not define what constitutes “new evidence.” In the commentary period, opponents to the proposed amended regulation posited that “new evidence” might mean new facts, or it might mean a new medical opinion based on the same facts, or something in between. DOL declined to provide a definition, leaving it to the parties and the courts to sort it out. In addition, the opponents argued that giving the claimant the last word for commenting on “new evidence” would cause an endless loop of back-and-forth and never permitting the insurance company to render a final decision.
So, what has happened after April 1, 2018? Some insurance companies have modified their appeal procedures and now routinely turn over to claimants new reports from consultants and provide claimants with a reasonable time period to respond. These companies do not distinguish claims filed or appealed, before April 1, 2018. Other insurance companies, however, take the position that the April 1, 2018 amendments to the regulations apply only to claims first filed after April 1, 2018.
On March 25, 2019, a District Court in Connecticut confronted this dilemma with an adverse-benefit determination for a claim that arose and was denied on appeal to an insurance fiduciary before April 1, 2018. Hughes v. Hartford Life and Accident Insurance Co., —F.Supp.3d—, 2019 WL 1324947 (D. Conn.2019): The Court found that the prior version of the regulations applied to the claim at issue, but nonetheless held that the “full and fair review” guaranteed by ERISA required that the insurer provide the plaintiff an opportunity to respond to new evidence prior to issuing an adverse benefits determination on appeal. Id. at *5, 14.
Patricia Hughes, a registered nurse, worked at Children’s Healthcare of Atlanta. In 2011 she developed dizziness and balance challenges, and reported that she could not walk, drive or work due to Meniere’s Disease and other ailments. Ms. Hughes applied for disability benefits with Hartford Life and Accident Insurance Company (Hartford), which administers and insures the ERISA disability benefit plan of her employer.
Hartford approved her claim and paid her benefits based on the effective disability date in 2012. Hartford gathered other evidence and terminated her claim on October 6, 2016. She appealed on March 28, 2017. Hartford sent her for a medical examination with a physician that its vendor selected. That physician sent a report to Hartford on May 23, 2017. Ms. Hughes requested a copy of the report so she could respond before Hartford made a final determination. Hartford refused and denied her appeal. The lawsuit followed.
The Court framed the case:
This is an ERISA case about what it means for an insurance company to give a “full and fair” review of a claim for disability benefits. The defendant insurance company terminated plaintiff’s disability benefits, once on an initial review and then again after plaintiff filed for an internal appeal review. But while the internal appeal was pending, the insurance company hired a doctor to examine plaintiff, and the doctor then sent the insurance company a report of his findings. Despite plaintiff’s request, the insurance company did not give plaintiff a copy of the doctor’s report, much less allow plaintiff to respond to the report. The company then denied plaintiff’s appeal, while relying heavily on the doctor’s report to do so.
Id. at *1.
The court began its analysis asking: “Just what does it mean to have a full and fair review?” In answering the question, the court remarked that the process boiled-down to “‘knowing what evidence the decision-maker relied upon, having an opportunity to address the accuracy and reliability of that evidence, and having the decision-maker consider the evidence presented by both parties prior to reaching and rendering his decision.’” (internal citations omitted). Id. at *5. In reaching this conclusion the court turned to the specificity of the regulations, which “creates three related rights for a claimant during the appeal process.” The court summarized the rights as: (1) a right to submit information to the plan for consideration on appeal; (b) a right of access to obtain information from the plan at the appeal stage relevant to the claim for benefits; (3) a right for the plan to consider the information submitted by the claimant at the appeal stage. Id. at *5-6.
The court concluded those rights together form “essential components of what the regulation defines to be a full and fair review” and the reasons a benefit plan or fiduciary must allow a claimant the right of access to a report of the physician and to respond to the physician’s report before the fiduciary makes a final determination. To hold otherwise, the Court reasoned, would make the regulations meaningless. “Full and fair review suggests a review that is thorough, comprehensive and transparent – not one in which a plan may order up a doctor’s report at the final hour and then deny the claimant access to this information until it is too late for the claimant to respond.” Id. at *9.
The court turned to an earlier opinion in which the Eighth Circuit had been offended by what amounted to sandbagging; in that case, the Court concluded that by not disclosing a report to the claimant, the insurer had failed to provide a full and fair review. Abram v. Cargill, Inc., 395 F.3d 882, 886 (8th Cir. 2005). The court addressed the cases which Hartford had cited where courts had ruled that similar reports did not need to be disclosed before making a final benefit determination: Midgett v. Wash. Group Int’l Long Term Disability Plan, 561 F.3d 887 (8th Cir. 2009); Glazer v. Reliance Standard Life Ins. Co., 524 F.3d 1241 (11th Cir. 2008); Metzger v. UNUM Life Ins. Co. of Am., 476 F.3d 1161 (10th Cir. 2007). Opposing those decisions, the court found a more recent opinion in the Ninth Circuit more persuasive under the general notion that sharing information fostered full and fair review. Salomaa v. Honda Long Term Disability Plan, 642 F.3d 666, 680 (9th Cir. 2011).
The court concluded that decisions of the Eighth, Tenth and Eleventh Circuits were inconsistent with the plain text of the regulations. The court cited the Secretary of Labor’s position on the timely disclosure issue as expressed in amicus briefs and in the Federal Register’s announcement of proposed changes to the regulations in 2016. The Court reasoned that the DOL’s recent regulatory amendments were made, essentially, to clarify that the DOL had always considered it “the plan’s duty to disclose new evidence on appeal,” stating that the DOL revised the regulations “in order to make explicit its prior interpretation of the rule and to correct the errant court rulings that misconstrued it.” Hughes, 2019 WL 1324947 at *14. In the end, the court concluded that Hartford’s refusal to turn-over the physician’s report violated Hughes’ right to a full and fair review and remanded the case to Hartford for reconsideration. Hughes, 2019 WL 1324947 at *14.
This is one court’s very thoughtful opinion. We cannot expect final resolution of this issue until circuit courts decide it, or so much time passes that no pre-April 1, 2018 claims exist.
This analysis is from the American Bar Association article written by Jonathan M. Feigenbaum.
by Cody AllisonWhat is the Standard of Review in an ERISA Case?
If you believe you have been wrongfully denied your ERISA, or non-ERISA, long-term disability benefits, give us a call for a free lawyer consultation. You can reach Cody Allison & Associates, PLLC at (615) 234-6000, or toll free (844) LTD-CODY. We are based in Nashville, Tennessee; however, we represent clients in many states (TN, KY, GA, AL, MS, AR, NC, SC, FL, MI, OH, MO, LA, VA, WV, just to name a few). We will be happy to talk to you no matter where you live. You can also e-mail our office at cody@codyallison.com. Put our experience to work for you. For more information go to www.LTDanswers.com
In the case of Dorris v. Unum Life Insurance Company of America, No. 19-1701, __F.3d__, 2020 WL 524726 (7th Cir. Feb. 3, 2020), the Seventh Circuit took a look at the standard of review and stated, “[a]t least in this this circuit, ERISA de novo review requires no review at all, but an independent decision.” The Court then proceeded to place the burden of proof of entitlement to benefits squarely on the shoulders of the plaintiff.
In the Dorris case, the Plaintiff had been receiving disability benefits from Unum for over 12 years, with the last 10 of which were received under the “any occupation” standard. Finally, Unum terminated the Plaintiff’s benefits claiming that she was now able to return to work in her own occupation. The Plaintiff took this before the district court which determined that this decision was incorrect because the Plaintiff’s occupation required long hours and was demanding mentally, and that these duties aggravated the Plaintiff’s Lyme disease symptoms.
However, the district court then look at whether the Plaintiff was entitled to benefits under her plan’s “any occupation” standard, not the “own occupation” standard which Unum had applied. The court found that there was hardly any evidence in the record which goes to that question. The court found that the burden of proving her case was on the Plaintiff and, since she had failed to conduct discovery on the merits of her case and failed to provide any additional evidence which would go to this question, her claim failed and the court decided in favor of Unum.
The court specifically set out that the word “review” in the de novo review standard was misleading — there actually is no review, but a brand new determination in an action like this, “akin to a contact dispute.” For this reason, the court said, the parties should be allowed to introduce new evidence which was beyond the scope of the administrative record, should they so desire.
Since the Plaintiff has the burden of proof in a de novo case, gaps in the record impact the Plaintiff’s claim. However, the Plaintiff should be allowed to patch these gaps before the court makes a final decision.
by Cody AllisonUse of Video Surveillance in ERISA Disability Cases
If you believe you have been wrongfully denied your ERISA, or non-ERISA, long-term disability benefits, give us a call for a free lawyer consultation. You can reach Cody Allison & Associates, PLLC at (615) 234-6000, or toll free (844) LTD-CODY. We are based in Nashville, Tennessee; however, we represent clients in many states (TN, KY, GA, AL, MS, AR, NC, SC, FL, MI, OH, MO, LA, VA, WV, just to name a few). We will be happy to talk to you no matter where you live. You can also e-mail our office at cody@codyallison.com. Put our experience to work for you. For more information go to www.LTDanswers.com
If you are making a disability claim under your company’s long or short term disability policy, it is important to document your medical problems by treating with a physician regularly. You may run into a situation where you are claiming that you have serious physical problems and the administrator of the plan my have you video recorded in public places or out in your yard to determine if your level of impairment is what you say it is.
In the case of Eaton v. Reliance Standard Life Insurance, 2018 WL 3639837 (W.D. Tennessee July 31, 2018) the Court had to examine the use of this video surveillance to discontinue benefits.
In the Eaton case, the Plaintiff had been receiving ERISA long-term benefits for several years for orthopedic/neurological impairments. The Plaintiff’s plan administrator had the Plaintiff video surveilled. The Defendant insurance company used these videos to justify stopping the benefit it was paying to the Plaintiff. The Plaintiff argued that the video surveillance was unauthorized, that it did not contradict anything he claimed as a disability and that the insurance company should not have relied solely upon what was contained in the videos without considering other evidence.
The Court disagreed. It held that the plan administrator is not required to ignore the inconsistencies between the video and the Plaintiff’s assessment of his condition or between the video and the level of activity the Plaintiff is able to perform. However, the Court held, these inconsistencies must be “more than minor.”
The Court did agree that the plan administrator could not use the video as the sole evidence in denying the claim, and specifically stated that the plan administrator could not base a denial or termination solely on the video.
The Court further pointed out that the length of the video was relevant and that a video lasting only 20 minutes, or with the activity of the Plaintiff being only a short part of a longer video, would not be given much weight as proof.
The Court did state that an independent reviewing physician’s opinion may be given greater weight when that physician relies on both the medical record review and video surveillance to form that opinion.
In short, the Plaintiff here lost because the videos of his activities were long (the Court states, “hours at a time”) and this was coupled with his medical records and so the Court upheld the termination.
by Cody AllisonNew ERISA Suit filed against Salesforce
If you believe you have been wrongfully denied your ERISA, or non-ERISA, long-term disability benefits, give us a call for a free lawyer consultation. You can reach Cody Allison & Associates, PLLC at (615) 234-6000, or toll free (844) LTD-CODY. We are based in Nashville, Tennessee; however, we represent clients in many states (TN, KY, GA, AL, MS, AR, NC, SC, FL, MI, OH, MO, LA, VA, WV, just to name a few). We will be happy to talk to you no matter where you live. You can also e-mail our office at cody@codyallison.com. Put our experience to work for you. For more information go to www.LTDanswers.com
For those of you who may not know, Salesforce is a software company that concentrates on customer relationship management, marketing automation, analytics and application development. This year, Fortune magazine voted Salesforce as number 6 on its list of top 100 companies to work for based on employee satisfaction.
Now, a suit has been filed in the U.S. District Court for the Northern District of California seeking class-action status for a group of retirement plan and long-term disability beneficiaries and recipients.
The suit alleges that Salesforce had over $2 billion dollars in assets as of the end of 2018 and that the size of its retirement plan gives it substantial bargaining power in order to negotiate lower fees for both investment products and bookkeeping services. However, the suit alleges, Salesforce failed to do so. The complaint alleges, ” “Defendants, however, did not try to reduce the plan’s expenses or exercise appropriate judgement to scrutinize each investment option that was offered in the plan to ensure it was prudent.”
Specifically, Salesforce is accused of failing to take advantage of low-cost share classes in mutual funds and failing to consider alternatives to mutual funds such as collective investment trusts.
Interestingly, the case filing documents show that Salesforce had actually made some of the changes by the time the suit was filed, but the suit alleges that these changes should have happened much earlier and that the fiduciaries should be financially responsible for reimbursement for these costs to the plan.
These kinds of suits are becoming more and more common under ERISA. Beneficiaries of retirement and long-term disability plans are starting to scrutinize fiduciaries for their actions in maintaining the benefit pool.
This case has not been resolved to date. We will be watching it and update this post as needed.
by Cody AllisonCOVID-19 and High Risk Individuals Under ERISA
If you believe you have been wrongfully denied your ERISA, or non-ERISA, long-term disability benefits, give us a call for a free lawyer consultation. You can reach Cody Allison & Associates, PLLC at (615) 234-6000, or toll free (844) LTD-CODY. We are based in Nashville, Tennessee; however, we represent clients in many states (TN, KY, GA, AL, MS, AR, NC, SC, FL, MI, OH, MO, LA, VA, WV, just to name a few). We will be happy to talk to you no matter where you live. You can also e-mail our office at cody@codyallison.com. Put our experience to work for you. For more information go to www.LTDanswers.com
In this time of the COVID-19 pandemic, we are getting questions about just how a person who might not be able to return to work because of some medical condition which might put them at an unacceptable risk should they contract the virus is to be treated under short and long term disability plans and under ERISA. The short answer to this question is that we just don’t know yet.
Generally, under most long term and short term plans, individuals who are not yet sick don’t qualify for benefits. So, as an example, let’s say that you have cystic fibrosis or muscular dystrophy, but it is being managed and you are still able to work. The management program involves an immunosuppressant. It would be very dangerous for you to return to work in an environment where the COVID-19 virus could easily be transmitted. What should you do?
The first thing you need to do is to check your policy. You will need to determine what the definitions of the words “sick” and “illness” are under your policy. Then, you will need to complete an application for benefits with your carrier, and make sure that the problems you set out fit within the definitions of your policy.
It is crucial when you do this that you set out the higher risk to you of exposure to COVID-19. In other words, you don’t want to just list muscular dystrophy or cystic fibrosis as the reason for your application — you need to clearly set out the increased risk of illness and/or death from the virus in light of your treatment for muscular dystrophy. In this circumstance, if your doctor is telling you of the danger of a return to work, it would be beneficial to have him put this in writing and attach it to the application. Be aware that even this tactic may not be successful in light of excusions for “future risk” or “possible loss.” Your policy may simply not cover you for what might happen but hasn’t yet happened.
This is the state of the law today. It may change. We are living in a new world now and the courts and policy makers are going to have to take this into account and make allowances. We will keep watching this area of the law will provide updates as we see them.
by Cody AllisonSignificant New ERISA Case on Statute of Limitations
If you believe you have been wrongfully denied your ERISA, or non-ERISA, long-term disability benefits, give us a call for a free lawyer consultation. You can reach Cody Allison & Associates, PLLC at (615) 234-6000, or toll free (844) LTD-CODY. We are based in Nashville, Tennessee; however, we represent clients in many states (TN, KY, GA, AL, MS, AR, NC, SC, FL, MI, OH, MO, LA, VA, WV, just to name a few). We will be happy to talk to you no matter where you live. You can also e-mail our office at cody@codyallison.com. Put our experience to work for you. For more information go to www.LTDanswers.com
As many of you may know, companies often fund their long-term and short-term disability policies by having the plan fiduciaries invest the company money in order to grow it over the long term to be able to pay benefits. Sometimes, these fiduciaries recklessly invest the money and it ends up significantly reduced or lost altogether, so that the company has no money to pay employee benefits. How long would an employee of a company have to bring a suit against these fiduciaries for dissipating this money?
The U.S. Supreme Court has addressed this issue in the case of Intel Corporation Investment Policy Committee v. Sulyma, case no. 18-1116. decided in the spring of 2020.
Under ERISA Section (413(2), a claim for breach of fiduciary duty can be brought within six years of the date of the breach. However, the statute of limitations date is shortened if the plaintiff in the suit had “actual knowledge” of the breach. The problem is that ERISA does not define what is meant by “actual knowledge.”
In this case, Sulyma filed suit within the six year limitations period, but outside the three year limitations period. The fiduciary argued that the three year limitations period should apply because Sulyma had received disclosures of the investments which would have given him actual knowledge of the bad investments. Sulyma testified that he did not recall reviewing these disclosures.
The district court granted summary judgment to the fiduciary, but the Ninth Circuit Court of Appeals reversed this. The Supreme Court unanimously affirmed this reversal. The Supreme Court held that the phrase “actual knowledge” means that the plaintiff must actually know about the alleged breach in order for the three-year statute of limitations to start. In coming to this conclusion, the Supreme Court rejected the argument that Section 413(2) of ERISA should be considered a “constructive-knowledge requirement” and that once a plaintiff receives a disclosure, he has the requisite knowledge since “he could acquire it with reasonable effort.” Evidence that the plaintiff had been provided with the relevant information is not sufficient for this purpose without additional evidence that the plaintiff actually read the materials that were provided. The decision states that the phrase “actual knowledge” must be given its plain meaning: “[r]eal knowledge as distinguished from presumed knowledge or knowledge imputed to one.”
by Cody AllisonAre Mental Health and Substance Abuse Disorder Benefits Available Under ERISA?
If you believe you have been wrongfully denied your ERISA, or non-ERISA, long-term disability benefits, give us a call for a free lawyer consultation. You can reach Cody Allison & Associates, PLLC at (615) 234-6000, or toll free (844) LTD-CODY. We are based in Nashville, Tennessee; however, we represent clients in many states (TN, KY, GA, AL, MS, AR, NC, SC, FL, MI, OH, MO, LA, VA, WV, just to name a few). We will be happy to talk to you no matter where you live. You can also e-mail our office at cody@codyallison.com. Put our experience to work for you. For more information go to www.LTDanswers.com
The question arises whether mental health befits and substance abuse disorder benefits available under ERISA. The answer lies in how the individual long-term disability plan is written.
In the case of Wit v. United Behavioral Health (No. 14-CV-02346 [and the related case No. 14-CV-05337-JCS]), the U.S. District Court in the Northern District of California ruled that if a company has a plan that allows for these type of benefits, the plan administrator may not abuse its discretion by adopting guidelines for the plan that:
Allows a conflict of interest in an attempt to keep expenses down and increase revenues into the plan;
Allows financial considerations to influence the development of the guidelines and not shielding the individuals who develop these guidelines;
Refuses to adopt generally accepted clinical guidelines despite the recommendations from clinicians to do so and against some states’ requirements stipulating standards of care.
The Court notes that a key issue raised in the case is the coverage for behavioral and substance use disorders as chronic, rather than acute conditions. The Plaintiffs argued that this distinction allowed for a termination of benefits once the conditions subsided and did not allow for long-term services needed to stabilize the condition.
by Cody AllisonERISA and Covid 19
If you believe you have been wrongfully denied your ERISA, or non-ERISA, long-term disability benefits, give us a call for a free lawyer consultation. You can reach Cody Allison & Associates, PLLC at (615) 234-6000, or toll free (844) LTD-CODY. We are based in Nashville, Tennessee; however, we represent clients in many states (TN, KY, GA, AL, MS, AR, NC, SC, FL, MI, OH, MO, LA, VA, WV, just to name a few). We will be happy to talk to you no matter where you live. You can also e-mail our office at cody@codyallison.com. Put our experience to work for you. For more information go to www.LTDanswers.com
Foremost on many Americans’ minds at this time is how the COVID 19 virus is going to affect their lives. Being a firm that handles ERISA cases, we have been curious as to how the virus will affect long term and short term disability plans.
On April 28, 2020, the U.S. Department of Labor released a set of FAQs designed to answer some of the most common and pressing questions about the relationship between the virus and ERISA plans, including health benefit and retirement benefit FAQs. Below, we have included a link to these FAQs.
Remember, if you have questions about your plan, call us. We can help!
by Cody AllisonChronic Fatigue Syndrome, Fibromyalgia and ERISA: Cochran v. Reliance Standard Life Insurance Co.
If you believe you have been wrongfully denied your ERISA, or non-ERISA, long-term disability benefits, give us a call for a free lawyer consultation. You can reach Cody Allison & Associates, PLLC at (615) 234-6000, or toll free (844) LTD-CODY. We are based in Nashville, Tennessee; however, we represent clients in many states (TN, KY, GA, AL, MS, AR, NC, SC, FL, MI, OH, MO, LA, VA, WV, just to name a few). We will be happy to talk to you no matter where you live. You can also e-mail our office at cody@codyallison.com. Put our experience to work for you. For more information go to www.LTDanswers.com
We often get questions about the whether or not claims can be successfully made for fibromyalgia and/or Chronic Fatigue Syndrome. This question was recently addressed in the case of Cochran v. Reliance Standard Life Insurance Company, et al, a case from the U.S. District Court for the Central District of California.
In this case, the Plaintiff appealed the denial of his disability benefits. The Plaintiff claimed that he was disabled based on having Chronic Fatigue Syndrome (CFS) and fibromyalgia. In the Findings of Fact and Conclusions of Law section of the opinion, the Court examined the relevant plan provisions and made an extensive examination of the medical history. The Court noted abnormal results of pulmonary testing and the diagnosis of possible CFS.
The Court further notes that the examining agency for the Defendant insurance company found that, while some weakness may have been found, most of the tests were within normal parameters. The insurance company’s report also heavily implied that the Plaintiff was merely malingering.
The Plaintiff than had a psychological evaluation where the doctor found that the Plaintiff was preoccupied with his medical condition, but could not say for certain that he as malingering.
Later medical reports show that the Plaintiff was improving and that his condition was somewhat managed with medication.
The Court examines all the proof and decides that the claimant must not be required to prove a subjective complaint (unmeasurable or not subject to proof by medical test or scan) by objective evidence, when the diseases in question — here CFS and fibromyalgia — are not objectively provable. The Court finds that forcing objective proof when it cannot exist is an abuse of discretion, as well as arbitrary and capricious. The Court found that the IME doctors on behalf of the insurance company had done just this. The doctors basically disregarded the Plaintiff’s subjective complaints and tried to make objective observations which is not possible for these types of conditions.
For these reasons, the Court reversed the insurance company’s decision and found the Plaintiff to be “totally disabled” under the terms of the plan.