Court Determines That Recognized Medical Conditions Without Objective Proof of Disability Will Still Support a Claim for Long-Term Disability Benefits
Claimants for long-term disability benefits often face an uphill battle with their insurers when their recognized medical condition lacks the kind of objective proof found in x-rays or blood work and instead, rely on the claimant’s subjective self-reports to their treatment providers. In one recent case, Vicky Myers v. Aetna Life Insurance Company, et al. 2020 WL 7423109 (2020), the U.S. District Court for the Central District of California found the insurer improperly based its denial of benefits on such a lack of objective evidence where the claimant was diagnosed and treated for fibromyalgia, chronic fatigue syndrome, and other conditions.
In 2003, Vicky Myers was experiencing pain, fatigue, and memory problems and was later diagnosed with fibromyalgia and chronic fatigue syndrome. She began suffering from reduced cognitive ability in April 2017, which made it difficult for her to do her job as a Software Management Engineer. At the time she was often working 12 to 14 hours a day managing at least six projects. She increasingly had trouble remembering, solving problems, and was more likely to make mistakes. Myers also experienced increased fatigue and muscle and joint pain requiring her to rest most of her weekends. In January 2018, Myers stopped working due to her health conditions.
Myers sought treatment from a variety of physicians and specialists who concluded that her worsening medical conditions meant she could no longer perform the duties of her job. Myers began occupational therapy for her chronic fatigue syndrome in February and her therapist put her on a plan to increase her executive functioning and problem solving skills. She began seeing a psychiatric therapist who noted Myers “had difficulty concentrating, intense and recurrent lethargy, extreme fatigue, and forgetfulness.” Another doctor noted Myers’ complaints of dull and constant body pains and that nothing seemed to alleviate her fatigue.
Myers submitted a claim for long-term disability with her employer’s insurance plan administered by Aetna and governed by the Employee Retirement Income Security Act (“ERISA”) in June 2018. Along with the claim application, Myers submitted statements from her treating physicians and specialists which described her medical conditions and said she was unable to concentrate, and could not work. Myers spoke with an Aetna representative and repeatedly emphasized that her cognitive decline was the biggest problem.
Aetna reviewed medical notes from Myers’ doctors and conducted its own review. A behavioral health clinician determined there was no evidence of a mental health impairment based on a review of the medical records and a call with Myers during which the clinician felt Myers “had no immediately apparent functional impairments ….” A nurse clinician also reviewed the medical records and stated there was no showing of “any organic cognitive loss or physical functional loss” because of Myers’ reported conditions. Aetna subsequently determined Myers was not disabled under the long-term disability policy and denied her claim in September of 2018.
In April 2019, Myers’ attorneys informed Aetna that she was appealing its denial. Myers submitted additional medical records including a report from a neuropsychologist stating Myers had a decline in visual memory and executive functioning, and her “cognitive difficulties interfere with her capacity for independence in daily life.” Additionally, she submitted a vocational assessment that found Myers was unable to perform her occupation. Finally, another doctor who had been treating Myers for a year stated she was completely unable to perform her job duties because of her conditions, particularly her neurocognitive impairment.
Aetna had Myers’ file peer reviewed by three third-party doctors. Two of the doctors did not discuss Myers’ cognitive issues but concluded the medical records did not show objective support for a claim of impairment, such as physical exams or testing. One doctor stated that, while fibromyalgia could result in subjective discomfort, there was no basis for restrictions on daily living or any functional impairment. Another emphasized the records were inconsistent because some of Myers’ doctors said she appeared normal during visits and her test scores were variable. Based on this inconsistency, the doctor concluded there were no confident findings of impaired cognitive function. Aetna denied Myers’ appeal in October 2019 and her attorneys filed suit in the U.S. District Court for the Central District of California.
Following a bench trial on the administrative record, the court issued its findings of fact and conclusions of law. Under a de novo review of a challenge to an insurance company’s denial of benefits under ERISA, the court had to determine if Myers had established that she was disabled under the terms of the policy. The court also noted that the relevant provisions of Aetna’s policy focused on Myers’ ability to perform the duties necessary to do her job so proving Myers’ suffered from her medical conditions was not enough, she had to prove that those conditions also caused a disability affecting her ability to do her job.
Despite Aetna’s arguments about the lack of objective evidence, the court recognized that Myer’s conditions of chronic fatigue and fibromyalgia “are all difficult to measure objectively through tests or other evaluations” and doctors must rely on their patient’s descriptions of their conditions and other subjective information.
The court quoted from Salomaa v. Honda Long Term Disability Plan, 642 F.3d 666, 678 (9th Cir. 2011) that “[m]any medical conditions depend for their diagnosis on patient reports of pain or other symptoms, and some cannot be objectively established until autopsy. In neither case can a disability insurer condition coverage on proof by objective indicators such as blood tests where the condition is recognized yet no such proof is possible.” Id. at 678. Additionally, the court quoted from the Seventh Circuit’s holding in Holmstrom v. Metro. Life Ins. Co., 615 F.3d 758 (7th Cir. 2010), “noting that for conditions like fibromyalgia, the court has ‘rejected as arbitrary an administrator’s requirement that a claimant prove her condition with objective data where no definitive objective test exists for the condition or its severity.’” Id. at 769.
Under ERISA, Aetna was not required to perform in-person medical evaluations. Nonetheless, the court was not persuaded by Aetna’s third-party doctors following their “paper” file review. The court discounted the conclusions to the extent they relied on inconsistencies in the records finding “such inconsistencies do not automatically negate any medical condition” nor do they show that Myers is unreliable and making a false claim. As noted above, two of the doctors did not even address Myers’ cognitive function, which was the main problem affecting her ability to work. Finally, the court found that one of the doctors unfairly minimized the effects of fibromyalgia by suggesting it cannot cause a disability, which is contrary to the Ninth Circuit’s holding in Salomaa and other cases. The court found credible the reports of Myers’ numerous treating physicians and specialists who concluded she was unable to work and that they were not only reliable measures of Myers’ medical condition, but also her ability to work.
The court found Myers’ met her burden of showing an entitlement to disability benefits and that her fibromyalgia and chronic fatigue interfered with the level of mental functioning necessary for her to perform the duties necessary for her job.
The findings in Myers are significant for those seeking long-term disability benefits for recognized medical conditions that do not provide the level of objective proof that insurance companies demand. The lack of such evidence may not be a bar to entitlements where statements by treating physicians and specialists are credible and support a finding of disability.
McKennon Law Group PC has significant experience in handling ERISA and non-ERISA insurance cases in which an insurer denied a claim. If your insurer or plan administrator has denied your claim, please contact us for a free consultation so that we may assess your matter.