Disabled claimants who suffer from conditions like myalgic encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) often face difficult hurdles in getting their disability benefits paid because of the subjective nature of these conditions. There is no objective test,such as an imaging study or blood test, to definitively prove that someone is feeling tired or weak. Yet, the medical community accepts ME/CFS as a complex and debilitating medical condition that often prevents people from doing their usual activities. Our client Nancy DeVries is afflicted with this condition and made a claim for short-term disability (“STD”) and long-term disability (“LTD”) benefits with her group disability insurer, Aetna Life Insurance Company (“Aetna”). After briefly paying her STD benefits, Aetna suddenly denied her claims, relying upon the reports of hired medical consultants who performed “paper reviews” of our client’s medical records and claimed that she had full-time work capacity. Our client hired McKennon Law Group PC to vigorously contest Aetna’s denial of her claims. We filed a detailed complaintunder the Employee Retirement Income Security Act of 1974 (“ERISA”) and took the matter to a bench trial.
In a 24-page opinion dated June 17, 2020, CentralDistrict of California federal court judge David O. Carter ruled in favor of McKennon Law Group PC’s client in her lawsuit against Aetna. DeVries v. Aetna Life Ins. Co., 2020 WL 3265108 (C.D. Cal. June 16, 2020). Judge Carterdiscussed several deficiencies in Aetna’s denial decision, focusing on the fact that Aetna did not consider Plaintiff’s “substantial and material acts necessary to pursue [her] own occupation,” and that the administrative record was “replete with evidence that Plaintiff suffers from a disability.” The court specifically noted numerous laboratory tests that produced abnormal results, the repeated notes and diagnoses offered by her attending physicians, including her diagnosis of Chronic Fatigue Syndrome. The court noted generally in Salomaa v. Honda Long Term Disability Plan, 642 F.3d 666, 678 (9th Cir. 2011) that the Ninth Circuit held that a “lack of objective physical findings” does not necessarily justify a denial of benefits; that is, a disability insurer may not condition coverage on proof by objective indicators such as blood tests where the condition is recognized even though no such proof is possible. DeVries, 2020 WL 32651108, at *8. Judge Carter also noted that the group policy at issue did not require “proof” to meet a specified degree of “objectivity,” nor did it exclude the presentation and consideration of subjective evidence, such as reports of a claimant’s symptoms. Id.
The court then underwent a detailed analysis of ME/CFS:
According to the U.S. Centers for Disease Control and Prevention (“CDC”): ‘[ME/CFS] is a disabling and complex illness’ which often prevents people from doing ‘their usual activities.’ The CDC notes that ME/CFS ‘changes people’s ability to do daily tasks, like taking a shower or preparing a meal,’ and ‘often makes it hard to keep a job, go to school, and take part in family and social life . . . Researchers have not yet found what causes ME/CFS, and there are no specific laboratory tests to diagnose ME/CFS directly. Therefore, doctors need to consider the diagnosis of ME/CFS based on in-depth evaluation of a person’s symptoms and medical history. It is also important that doctors diagnose and treat any other conditions that can cause similar symptoms.’ DeVries, 2020 WL 32651108, at *9.
Based on its analysis of ME/CFS, the court found that Plaintiff had demonstrated by a preponderance of the evidence that she suffers from clinically evaluated, unexplained and persistent chronic fatigue of new onset as of approximately August 2016. Id. at *10. The court pointed to Aetna’s own paper reviewer who found that Plaintiff’s complaints of fatigue were consistently noted throughout the course of treatment and that she sufficiently provided evidence of tender lymph nodes, muscle pain, multi-joint pain, unrefreshing sleep and post-exertional malaise. Id. Because of this, the court found that “at the very least, then, the Administrative Record suffers from Chronic Fatigue Syndrome.” And, given the nature of her condition, the court found Plaintiff’s treating physicians to be more reliable witnesses than Aetna’s hired paper reviewers who failed to examine her in person. Id.
The court also considered the relevant standard of disability under Plaintiff’s policy with Aetna: that her disease or disability prevents her from performing the substantial and material acts necessary to her own occupation. The court found that Plaintiff consistently represented that she suffered from severe fatigue, sometimes to the degree that she was unable to get out of bed. Judge Carter wrote, “It is obvious that her fatigue would impair her ability to carry out the wide array of analytical, strategic, and material tasks that were expected of her in the regular course of her own occupation as a Senior Business Analyst.” Id. at *11. The court criticized Aetna’s application of this standard, as Aetna had only considered whether she could perform a sedentary occupation. Judge Carter noted that substantial and material acts may include a level of physical activity, but there is no basis for interpreting “substantial and material acts” as defined by or limited to the physical activity of an occupation. Id. at *9, citing Sabatino v. Liberty Life Assurance Co. of Bos., 286 F.Supp.2d 1222, 1232 (N.D. Cal. 2003) (“Inability to perform sedentary work is not the definition of disability set forth in the policy. The relevant definition of disability in the policy is ‘unable to perform all of the material and substantial duties of his occupation on an Active Employment basis because of an injury or sickness.’”).
Ultimately, Judge Carter found that our client was totally disabled from performing the material duties of her own sedentary occupation. The court awarded our client all of her benefits for the Policy’s “own occupation” period, plus prejudgment interest and our attorneys’ fees and costs. The order from the court will allow our client to collect all of her substantial attorneys’ fees and costs that she incurred while aggressively fighting Aetna for the last two years.
This decision provides substantial support to claimants who have subjective symptomology that is difficult to objectively measure. We often see insurers deny claims of our clients who suffer from chronic pain, Chronic Fatigue Syndrome, fibromyalgia, migraine headaches and other syndromes. Insurers may deny these claims based upon a “paper review” medical consultant who reviews medical records and forms an opinion on a claimant’s restrictions and limitations. This presents a difficult task for both the claimant to prove their own subjective conditions and for insurers to verify the legitimacy of claims. Thankfully, the Ninth Circuit protects claimants who suffer from these conditions. The DeVries opinion clarifies and substantiates the Ninth Circuit’s precedent and importantly considered that an “own occupation” policy definition does not simply mean a sedentary job. In fact, insurers must consider the analytical, strategic and managerial tasks that are expected of employees in the regular course of their occupations, not simply the physical requirements.
If your insurance company or plan administrator has mishandled or denied your claim, please contact our firm for a free consultation. We have extensive experience handling long-term disability claim denials under both ERISA and non-ERISA cases.