The
following summary of an appellate court decision should be helpful for any
person with an illness such as CFIDS for which there is no known objective test
to prove the cause or severity of the disability. The full text of this
decision Mitchell v. Eastman Kodak, docket # 96-7034 (May 8) is available on
the Internet at: http://www.ljextra.com/courthouse/feddec.html- Go to decisions
filed on May 8, 1997. Filed May 8, 1997 UNITED STATES COURT OF APPEALS FOR THE
THIRD CIRCUIT NO. 96-7034 GEORGE W. MITCHELL v. EASTMAN KODAK COMPANY Appellant
According to the record before us, the Administrator denied Mitchell's claim
for LTD benefits because Mitchell had failed to tender "objective medical
evidence" that he was unable to engage in any substantial gainful work as
of June 26, 1989. We hold that, in this context, it was arbitrary and
capricious for the Administrator to deny Mitchell LTD benefits for this reason.
I.
See Letter of Jan. 17, 1992, App. at 24 ("The file indicates that you are
suffering from fatigue, but does not contain objective medical evidence that
your condition made you totally and continuously unable to engage in any
substantial gainful work for which you were qualified as of June 26,
1989.") (emphasis in original); Letter of Apr. 12, 1995, App. at 193
(informing Mitchell's attorney that denial of benefits was affirmed because
"you and your client have failed to provide any objective medical evidence
that his condition made him totally and continuously unable to engage in any
substantial gainful activity for which he was qualified as of June 26,
1989.") (emphasis in original).
The
Administrator's denial letters are terse, and we are not altogether certain of
their meaning. However, we find the denial arbitrary and capricious under
either of the possible meanings we can divine. The Administrator may have meant
that Mitchell had tendered insufficient evidence to persuade the Administrator
that Mitchell experienced chronic and unpredictable fatigue and loss of
concentration or that he experienced those symptoms to a sufficient extent to
foreclose his holding down paid employment. If that was the Administrator's
meaning, his denial of benefits on that ground was arbitrary and capricious
because the undisputed facts of record are to the contrary. As we have already
described, the undisputed evidence from Mitchell's physicians indicates that
Mitchell has suffered severe CFS symptoms that have precluded him from engaging
in any substantial gainful work since January 1989. Kodak has identified no
more "objective" evidence that Mitchell could have submitted, in
addition to his doctors' observations, to support his claim that his fatigue
and loss of concentration were sufficiently severe to prevent him from engaging
in ainful work.
Because
the Administrator cited a lack of "objective medical evidence," as
opposed to merely "objective evidence," we think it more likely that
the Administrator meant that Mitchell had failed to submit clinical evidence
establishing the etiology of the chronic and unpredictable fatigue and loss of
concentration that disabled him from working. Although in some contexts it may
not be arbitrary and capricious to require clinical evidence of the etiology of
allegedly disabling symptoms in order to verify that there is no malingering,
we conclude that it was arbitrary and capricious to require such evidence in
the context of this Plan and CFS.
The
Plan requires that a claimant for LTD benefits "[m]eet the definition of
Disability," i.e. be "totally and continuously unable to engage in
any substantial Gainful Work for which he is, or becomes, reasonably
qualified" for at least 26 weeks. See Plan §§ 2.06, 4.01. Nowhere does the
Plan state that a claimant must provide clinical evidence of the etiology of
the "condition" that renders him disabled. Cf. Dewitt v. Penn-Del
Directory Corp., 106 F.3d 514, 520 (3d Cir. 1997) (administrator's
discretionary interpretation of plan "may not controvert the plain language
of the [plan] document") (citing Gaines v. Amalgamated Ins. Fund, 753 .2d
288, 289 (3d Cir. 1985)). All that the Plan required was that Mitchell show
that he was in fact "disabled" as of June 26, 1989, and this he did.
See supra Part II-B-2.
Moreover,
it was impermissible for the Administrator to imply an additional
"clinical evidence of etiology" requirement not specified in the Plan
document in the context of CFS. It is now widely-recognized in the medical and
legal communities that "there is no `dipstick' laboratory test for chronic
fatigue syndrome." Sisco v. United States Dep't of Health & Human
Services, 10 F.3d 739, 744 (10th Cir. 1993). Because the disease, although
universally- recognized as a severe disability, has no known etiology, see,
e.g., Rose v. Shalala, 34 F.3d 13, 16-17 (1st Cir. 1994), it would defeat the
legitimate expectations of participants in the Kodak Plan to require those with
CFS to make a showing of clinical evidence of such etiology as a condition of
eligibility for LTD benefits. Thus, it was arbitrary and capricious for the
Administrator to deny Mitchell benefits because of a lack of such clinical
evidence of the etiology of his CFS
III.
Conclusion In accordance with the foregoing, we hold that the Kodak Plan
Administrator's decision to deny Mitchell's claim for LTD benefits was
"arbitrary and capricious." We will affirm the district court's grant
of summary judgment for Mitchell.
A True Copy:
Teste:
Clerk of the United States Court of Appeals for the Third Circuit