Archives for April 25, 2016

Insureds suffering from disabling conditions that cannot be objectively verified (for example pain, fatigue, migraines, and confusion) are often denied long-term disability benefits because of the difficulty of proving their claims.  In an attempt to deny a claim for disability benefits, a plan administrator will often assert that there is not enough objective evidence to support a disability classification under the terms of the policy.  Most often, these disabling conditions render the insured incapable of pursuing either their own occupation or any gainful occupation, and the insured’s condition satisfies the definition of total disability within the policy at issue.  However, insureds do not necessarily need to provide objective evidence of a disabling condition that inherently cannot be proven with objective evidence, even when satisfactory proof of such a condition is required by the policy.  Recently, Fernando M. Olguin, United States District Judge for the District Court for the Central District of California, outlined evidence an insurer must consider in determining whether an insured is entitled to disability benefits under ERISA due to a disorder that is not capable of objective proof.  Pamela Jahn-Derian v. Metropolitan Life Insurance Co., No. 2:13-cv-07221-FMO-SH, 2016 WL 1355625 (C.D. Cal. March 31, 2016).

In Jahn-Derian, the plaintiff was a Director of Risk Management and Patient Safety at a medical center.  Id at *2.  She suffered from severe neck and extremity pain due to cervical spondylosis, which ultimately required her to resign from her job.  Id.  MetLife concluded that despite Ms. Jahn-Derian’s injuries, there were no significant neurological abnormalities found upon physical examination, and thus seated, sedentary work should be possible.  Id at *3.  In support of her appeal, Ms. Jahn-Derian provided MetLife with letters from her doctor explaining that she was unable to return to work, a narrative explanation of her condition, letters from her friends and neighbors and letters from her colleagues describing their observations of the pain she was experiencing and her inability to perform her job duties.  Id at *5.  MetLife denied the appeal, stating that the medical information “lacked any significant objective exam findings that would support the extremely restrictive limitations” given by her doctor.  Id at *4.

The District Court reversed the plan administrator’s decision and granted Ms. Jahn-Derian disability benefits. Id at *12.  The court determined that the plaintiff’s pain allegations were supported by objective medical evidence because her pain was diagnosed as a symptom of her cervical spondylosis and her medical records reflect her complaints of severe pain.  Id at *8.  The court then stated that even if the plaintiff had not submitted objective medical evidence to support her pain allegations, it would not undermine her claim because subjective complaints can form the basis of a disability claim, even when no objective medical evidence is available to verify or measure the pain.  Id at *9.  The court then concluded that MetLife did not give adequate consideration to the letters from the plaintiff’s colleagues as they constituted competent evidence that must be considered in evaluating plaintiff’s symptoms and how her pain affects her ability to work.  Id at *10.

As demonstrated by the Jahn-Derian case, doctors who have regularly treated an insured are in the best position to observe the insured’s symptoms, intentions, and ability to work.  Id at *9.  Opinions of non-examining physicians, hired by the insurer only to review an insured’s records, are typically far less persuasive than the opinions of treating physicians.  This is why it is extremely beneficial when an insured obtains letters from their doctors not only describing the reported symptoms, but also providing a supported opinion on the insured’s inability to work and their perception of the insured’s credibility in reporting such symptoms.  As is often the case, the claims administrators such as the one in Jahn-Derian focus solely on the lack of objective evidence and fail to address whether the insured’s pain symptoms might affect his or her ability to adequately perform his or her occupation.  The Court pointed out that the inability to focus and concentrate due to ongoing symptoms must be considered in determining whether the insured can perform the substantial and material functions of her job.  Id.  The court stated that the letters from the insured’s colleagues regarding the effect of her symptoms on her ability to work “constitute competent evidence that must be considered in evaluating plaintiff’s symptoms and how her pain affects her ability to work.”  Id at *10.

As routinely recognized by the courts, subjective complaints can form the basis of a disability claim, even when no objective medical evidence is available to verify or measure the subjective complaint.  When denied disability benefits, an insured that lacks objective evidence of the severity of their symptoms should seek not only letters from treating physicians, but also letters from co-workers and friends who have observed their symptoms and can demonstrate that the insured’s symptoms negatively affect the insured’s ability to perform his or her job.