Many disability insurance policies provide benefit payout periods that are much longer for disabilities caused by physical conditions as opposed to mental conditions. Typically, while allowing benefits for disabilities caused by mental or nervous conditions are paid only for a limited time period, often two years. Additionally, insurance companies operate for the purpose of generating profit and therefore have a substantial financial motivation to avoid paying benefits whenever possible. If an insurance company is unable to justify denying a disability claim outright, the next best action they can take to save money is to limit the benefits it pays out to as short a period as possible. Thus, given the choice between paying benefits related to a physical condition versus a mental or nervous condition, any insurance company will logically prefer to only approve a claim for a mental or nervous condition, and not for a physical condition. To complicate matters, there are many times when a claimant suffers from both a physical condition and a mental/nervous condition, which may or may not be separately disabling. On top of this, some disabling conditions, such as chronic fatigue syndrome, are subjective in nature, lacking objective testing.  When a claimant is disabled due to such a condition, it will be difficult, if not impossible, to provide objective evidence to the insurance company to prove such a disability.

A recent District Court decision, Veronica L. v. Metropolitan Life Insurance Company, 647 F.Supp.3d 1028 (D. Oregon 2022), sheds light on how insurance companies handle claims based on subjective conditions and how claimants can recover their much-needed benefits. The plaintiff, Veronica, made a claim for long-term disability (LTD) benefits with MetLife. She had been diagnosed with PTSD, major depressive disorder, and generalized anxiety disorder, all mental/nervous conditions. She had also been diagnosed with chronic fatigue syndrome (CFS).

MetLife approved Veronica’s claim for LTD benefits based on her PTSD, anxiety, and depression. During its review of her claim, MetLife conducted a “paper review” of her medical records, done by a physician who reviewed Veronica’s medical records without examining or speaking directly with her. The paper review physician concluded that Veronica had no restrictions or limitations caused by CFS, supporting the conclusion with vague language: “based on the medical documentation, it is understood that the claimant’s low energy [is] likely related to psychological condition.” A second paper review physician also “found insufficient support for a diagnoses of CFS” based only on Veronica’s medical records, which included no interaction with Veronica and no discussion with her treating physicians.

Veronica began treating with a new physician who noted that she had fatigue that had progressively worsened over the previous three years. The new physician provided records to MetLife, but by the time MetLife received the records, it had already determined that Veronica was entitled to LTD benefits subject to the mental/nervous limitation of three years. Veronica appealed MetLife’s decision, highlighting records and notes from her physician supporting her position that she was disabled due to CFS, a physical condition, independent of her mental/nervous conditions.

In reviewing Veronica’s appeal, MetLife hired a third paper review physician, who’s opinion was, predictably, that Veronica had no restrictions or limitations based on CFS, “given the lack of objective evidence.” In response to this, Veronica’s treating physician asserted that CFS is difficult to assess through objective evidence but rather is determined by personal interaction with the patient. Simply put, CFS is inherently subjective in nature and objective evidence, such as imaging or lab work, does not exist. This did not change the opinion of the paper review physician, who again pointed to a lack of objective evidence to support his conclusion that Veronica was not disabled due to CFS.

The court decided the matter on de novo review, meaning that it would determine in the first instance if Veronica had adequately established that she was disabled under MetLife’s plan. After reviewing the evidence, the court found that MetLife had based its decision on incomplete information and had erred by failing to conduct an independent medical exam (IME). Citing Salomaa v. Honda Long Term Disability Plan, 642 F.3d 666 (9th Cir. 2011), the court noted that there are no objective laboratory tests for CFS, its etiology is unknown, and a diagnosis of CFS is based on a patient’s subjective reports of symptoms, reviewing her medical history, and ruling out other disorders. Because there was no means of objectively proving that she had CFS, evaluating Veronica’s disability was essentially a credibility determination.

The court found that Veronica’s treating physicians provided credible evidence that she in fact suffered from CFS; the evidence included a substantial history of subjective complaints by Veronica regarding her lack of energy, her inability to perform more than one major task per day, the fact that she no longer was able to do activities she had previously enjoyed, and requiring abnormally long periods of sleep. Additionally, Veronica had sought treatment for her CFS for several years but had not been able to find any treatment that alleviated her symptoms.

Because Veronica had presented evidence that she was disabled due to CFS, including her uncontested diagnosis of the condition, her own statement about her subjective symptoms, and corroborating statements made by her treating physicians, the court explained that because CFS cannot be objectively measured, MetLife would need to make a determination that Veronica’s claim was not credible in order to justify denying her LTD benefits beyond the mental/nervous limitation period.

The court explained that MetLife had a duty to conduct an adequate investigation of Veronica’s claim, citing Petrusich v. Unum Life Ins. Co. Of Am., 984 F. Supp. 2d 1112 (D. Or. 2013). While ERISA did not require MetLife to conduct an IME, failure to do so may raise questions about the thoroughness of its review and determination. The court noted that failure to conduct an IME may be particularly dubious when a claimant’s condition is based on subjective symptoms, citing Robertson v. Stand. Ins. Co., 139 F. Supp. 3d 1190 (D. Or. 2015). In this case, MetLife could have conducted an IME, which could have provided the evidence it needed to determine whether Veronica was disabled from CFS but declined to do so. Especially considering that MetLife expressed doubt as to Veronica’s credibility and the severity of her subjective symptoms, for MetLife not to conduct an IME meant that its decision was based on inadequate evidence. None of Veronica’s treating physicians ever questioned her credibility, nor did they opine that she exaggerated symptoms yet MetLife still discredited her subjective symptoms anyway, without providing any rationale for doing so. However, MetLife was obligated to consider Veronica’s self-reported symptoms because no objective tests exist for CFS; MetLife could not condition her LTD benefits on objective proof of CFS because it is a recognized condition but is not objectively provable.

ERISA does not have a rule requiring treating physicians’ opinions to get more deference than other physicians but treating physicians have more opportunity to know and observe a patient than those who have not examined the patient. See Black and Decker Disability Plan v. Nord, 538 U.S. 822 (2003). Especially with a condition like CFS, which requires examination of a patient’s symptoms and medical history, that patient’s treating physician is likely in a better position to diagnose such a condition than a paper review physician. In this case, MetLife’s paper review physicians did not provide any explanation for discounting the opinions provided by Veronica’s treating physicians, who had expertise with CFS. Thus, MetLife’s decision was improper.

It is vital to understand your insurance company’s obligations in reviewing your disability claim. Especially if your condition is something like CFS, for which objective evidence is impossible to provide, accepting the insurance company’s denial of your claim may be tantamount to foregoing disability benefits to which you may be entitled. To avoid such circumstances, you should consult with an expert disability insurance claims attorney with expertise and knowledge of ERISA and insurance companies’ obligations. The team of attorneys at McKennon Law Group PC have exactly such expertise and knowledge and can help you navigate your disability claim and appeal of the insurance company’s denial of your claim. If you have made a claim for disability benefits or intend to do so, contact McKennon Law Group PC immediately for a free consultation.