US CASE LAW AND STANDARD OF PROOF
for
CFS, FM, CHRONIC PAIN
AND OTHER “SUBJECTIVE” DISABILITIES.

Taken from http://personal.riverusers.com/~searcher/help/cases.html

From ERISA Cases Index

Ace v. Aetna, (9th Cir., 1998) No. 96-35813, 96-36020

In this non-ERISA disability case the jury awarded Ace $16.5 Million dollars in punitive damages. Plaintiff’s LTD claim was known to be only temporary if she could get the required surgery on her knee. However, her doctors required her to heal from the previous surgery first. Meanwhile she would continue to suffer debilitating pain and immobility. Aetna denied the LTD requests even though plaintiff’s financial situation was desperate. Aetna’s investigation was very incomplete and ignored much of the information they had requested from plaintiff. They used policy definitions that were not legally binding and refused to answer Ace’s questions or provide her with adjustment guidelines. Aetna lied and claimed they had no “claim adjustment guidelines” even though a manual was produced during discovery entitled “Proper Claim Handling Guidelines.” Ace was forced to sell her home, most of her possessions and lived in her car for several months. Ace’s subsequent surgery was successful and she returned to work.

The appeals court unfortunately thought the punitive damages were excessive although they agreed with the district court that punitive damages were warranted due to Aetna acting with “malice, bad motives or reckless indifference.” The Appeals Court found that punitive damages were warranted based on Aetna’s (1) basing denial of the claim on an illegal standard for benefit eligibility; (2) failing to inform the claimant of the standard actually used by Aetna in evaluating disability claims; (3) failing to investigate the claim and to seek or request the supporting information alleged to be missing; (4) failing to assist the claimant in presenting her disability claim; (5) relying on outdated prognoses of the claimant’s expected recovery and disregarding recent reports of her actual condition; (6) denying her claim based on an undefined “requirement” not a term of her policy and contrary to Aetna’s internal claim adjustment guidelines; (7) falsely advising the claimant that Aetna had no claim adjustment guidelines; and (8) making a last-minute demand for an IME after having denied the claim.”

(The Appeals Court said:) “When an insurance company wrongly refuses to honor its obligations, emotional distress is a natural and believable response. Insureds bargained and paid for the security and peace of mind of knowing that reimbursement and financial support would be provided in the event that a misfortune occurs. As insurance payments often serve as a safety net for the insured, Aetna’s refusal to cover Ace’s injury is foreseeably egregious.”

In an irrational opinion however they denied Aetna’s motion for new trial on the punitive damages only if Ace would accept $381,000 instead of the jury’s verdict of $16 Million although Judge Fletcher dissented with the following statements:

The majority pays only lip service to the Alaska Supreme Court’s determination that the facts, and not the ratio, drive the results of a review of punitive damages.” “the facts of this case would support a much higher award" As to the 'magnitude of the offense,' we need only look to the harm caused to Ace, harm that her insurance was intended to avoid. She lost everything she had, including her home; she had to live in her car; and she had to send her child away because she couldn’t care for him. Next, with respect to the ‘importance of the policy violated,’ Aetna’s wrong and bad faith refusal to cover Ace implicated a much broader company policy of wrongfully denying coverage to many who met the definition of ‘disabled,’ exhibiting a callous breach of trust owed to their insureds at a time when they are most vulnerable. Finally, the defendant’s wealth' is estimated at 1.7 billion dollars and the evidence presented demonstrates that Aetna’s assets would not be sufficiently diminished by the punitive damages award set by the majority. Punitive damages by definition are to be adequate in amount to punish the offender.”

The court then issued an amended opinion stating that the amount of punitive damages could be reduced but the amount would be determined by the district court and deleted the dissenting opinion. They also awarded costs to Ace.

 

Armstrong v. Aetna, 8th Cir. Appeals Court, No 97-1712, 1997

The Court found that Aetna “by reasoning of the Eleventh Circuit’s holding in Brown, which stated that a relationship that places an ERISA benefits plan administrator in 'perpetual conflict’ warrants a higher level of scrutiny. [Brown, 898 F.2d at 1561.] Aetna faces a continuing conflict in playing the dual role of administrator and insurer of the health benefits plan. As the insurer, Aetna has an obvious interest in minimizing its claims payments. Apparently to limit claim payments, Aetna provides incentives and bonuses to its claims reviewers based on criteria that include a category called ‘claims savings.’ …… Despite Aetna’s argument that there is no evidence that Aetna has directed its reviewers to improperly reject claims, we cannot view the fiduciary arrangement between Aetna, its claims reviewers, and the plan beneficiaries as the type ERISA provides as administered ‘solely in the interest of the participants and beneficiaries.’ [29 U.S.C. § 1104(a)(1).]

 

Bellaire Gen. Hosp. v Blue Cross Blue Shield of Mich, 97 F.3d 822, 831 (5th Cir. 1996)

Held that insurance company’s denial of payment for psychiatric treatment, based on the application of standards not contained in the plan, was arbitrary and capricious.

 

Booton v. Lockheed Medical Benefit Plan 110 F. 3d 1461 (9th Cir., 1997)

...“To deny the claim without explanation and without obtaining relevant information is an abuse of discretion”

 

Bouchard v. Crystal Coin Shop, Inc., 843 F. 2d 10 (1st Cir. 1988)

[W]here the trustees of a plan impose a standard not required by the plan’s provisions, or interpret the plan in a manner inconsistent with its plan words, or by their interpretation render some provisions of the plan superfluous, their actions may well be found to be arbitrary and capricious.”

 

Brown, 898 F. 2d at 1561

Because an insurance company pays out to beneficiaries from its own assets rather than the assets of a trust, its fiduciary role lies in perpetual conflict with its profit-making role as a business.”

 

Chambers v. Family Health Plan Corp., 100 F.3d 818, 826 (10th Cir. 1996)

When an insurer may promote the potential for its own profit by denying plan participants claims, deference to its decision in a particular case will be lessened to the degree necessary to mutualize that conflict.”

 

Clausen v. Standard Insurance Co., 961 F. Supp. 46 (D. colo. 1997)

The Court recited the uncontroverted medical evidence that Clausen suffered from CFS and noted that none of the independent examiners to whom Standard referred Clausen disagreed with the CFS diagnosis. Id. at 1455-56. The Court said: “Standard’s attempt to ignore the CFS diagnosis of Clausen’s treating physicians and to require instead, that Clausen provide “objective” evidence of a distinct physical disease” runs afoul of established law in this circuit.” Id. at 1456.

Citing Sisco v. United State Department of Health and Human Resources, [10 F.3d 739 (10th Cir. 1993)], the Court found that:

the lack of objective’ medical evidence to ‘prove’ Clausen was disabled by her fatigue and pain cannot constitute substantial evidence that Clausen was not disabled, i.e. that she was capable of full-time work. I now find in addition that neither the surveillance video nor Dr. Thompson’s report constitute such evidence.”

 

Cohen V. Secretary of H.H.S. 964 F2d 524 (6th Circuit 1992)

(Plaintiff was a CFS patient who finished one year of Law School in three years.) The court saw her activity as a tribute to her courage and determination in refusing to surrender to the debilitating affects of her illness. They went on to acknowledge that “CFS is characterized by exacerbations and remissions which are unpredictable in nature and which make sustained work activity virtually impossible”

the exact causes of chronic fatigue syndrome are still being explored.”

 

Dishman v. UNUM, 96-0015JSL, Federal Court C.D. May 9, 1997

The insurer engaged in tactics designed to force the insured into accepting a much lower offer than what would have been reasonable. Ultimately the insurer terminated benefits altogether, and the claimant sued.

The Court was appalled by the insurer’s conduct and explicitly found that such conduct “may be closer to the norm of insurance company practice than the Court has previously suspected” The Court added that the facts of the case were disturbing” and illustrated that the absence of penalties results in “no practical or legal deterrent to unscrupulous claims practices.”

The court suggested that the “public interest would be served if ERISA contained a statutory penalty which could be imposed by the Court in extraordinary cases.”

Furthermore Judge Letts stated that the plaintiff “suffered irremediable harm as a result of the termination of benefit payments to him. He has been forced to sell stocks and make distributions from his IRA in order to pay living expenses. As a consequence, he has incurred taxable income which might have been deferred or avoided. Mrs. Dishman has been required to return to full-time employment. Finally the purpose of disability payments is to provide a disabled individual with periodic income with which to pay living expenses. The receipt of a lump sum at the conclusion of an appeal of this case will not compensate Mr. Dishman for his loss of periodic income.”

 

Dorsk v. UNUM, No 97-87-P-C (Me.d.Apr.10,1998)

Plaintiff was disabled with Obsessive Compulsive disorder. UNUM paid two years then terminated benefits under Mental Illness Limitation Clause of policy. Plaintiff’s doctor and current medical science consider Obsessive Compulsive Disorder not “mental” but neurobiological. UNUM’s claim for summary judgment was rejected by the court on the grounds that the contract language was ambiguous”. The Federal District Court applied the doctrine of Contra Preferentum, strictly construing the terms against the insurer.

 

Duncan v. Continental as. Co., 1997 WL 88374, 4-5(N.D. Cal 1997)

Held that denial of claim for long term disability based on objective medical evidence requirement that was not in the plan was arbitrary and capricious and that fiduciaries may not deny claims because physicians “cannot provide physiological proof where the physical condition is such that physiological proof is not available.”

The Duncan court stated that Continental cannot exclude a claim for lack of “objective medical evidence” unless the “objective medical evidence” standard was made “clear, plain and conspicuous enough [in the policy[ to negate layman [plaintiff’s] objectively reasonable expectations of coverage.” Id. citing Saltarelli v. Bob Baker Group Medical Trust et al, [35 F. 3d 382, 387 (9th Cir. 1994)]. The court further concluded that the denial of Duncan’s claim was not sustainable under the de novo or arbitrary and capricious standard. It stated, in pertinent part:

[M]edical conditions that do not give rise to hard laboratory facts or data may still be cognizable claims. In the medical opinion of Duncan’s physician, the plaintiff has exhibited symptoms associated with fibromyalgia or CPS [chronic pain syndrome] and has become totally disabled as a result….Continental cannot deny Duncan’s claim because her physical condition is such that physiological proof is not available.”

 

Egert v. Connecticut Gen. Life Ins. Co., 900 F.2d 1032, 1037-1038 (7th Cir. 1990)

Held that denial of benefits based upon guidelines that contradict plan language is arbitrary and capricious

 

Fisher v. Aetna, Appeal from Superior Court for the State of Alaska, Third Judicial District, Case No. 3AN-97-00297

Appeals Court upheld a jury verdict against Aetna in the amount of $292,000 in compensatory and $8,400,000 in punitive damages in a non-ERISA case stating the following:

Fisher’s evidence described a corporate calculated risk which encouraged shoddy claims investigation and banked on the fact that sick and elderly disabled claimants ordinarily don’t file lawsuits. Fisher also presented evidence that Aetna attempted to prevent discovery of its misconduct after he complained.

The jury construed the conflicting evidence in Fisher’s favor, finding that Aetna acted outrageously……Because reasonable jurors could differ regarding those conclusions, and passion or prejudice did not unfairly influence this verdict, Aetna’s motions for judgment notwithstanding the verdict, new trial or remitter are DENIED.

Trial by jury is a basic constitutional right.

Other evidence also supports a finding that the investigation was unreasonable, and that Aetna’s denial was made without a reasonable basis, including:

·         Aetna failed to obtain all of Mr. Fisher’s treating physician’s records, and did not speak with the doctor about Fisher’s condition;

·         When Fisher’s cardiologist did not respond to Aetna’s first request for information, Aetna failed to follow through by making a second attempt or by calling the doctor;

·         Aetna never spoke with Mr. Fisher about the impact of his medical condition on his daily life and ability to work;

·         Aetna based its decision, in part, on selected portions of Fisher’s medical records (i.e. “doing great today”), yet didn’t investigate other portions of the records suggesting that Fisher had serious medical problems (including significant swelling and inability to stand or walk for other than short periods of time).

The evidence also supports a jury finding that denial of Fisher’s claim was not an isolated, honest mistake, and that Aetna acted maliciously or with reckless indifference to Fisher’s rights as a policy holder.

Fisher’s insurance expert Prater testified that insurers are generally aware that disability applicants tend to give up and drop their applications if the insurer makes the process too difficult. Aetna told Fisher that if he wanted further information regarding denial of his claim he would have to serve a ‘subpoena.’ After Fisher filed his suit, Aetna concluded that its denial of Fisher’s claim was likely invalid. Yet, Aetna vigorously disputed the claim throughout the litigation, until the third week of trial, when Ms. Gorna conceded that Aetna’s handling of the claim was unreasonable.”

Aetna’s employees conceded that disability applicants are among the most vulnerable insurance claimants…. Fisher also described his fear and anguish when his application for benefits was denied, and when his continued efforts to convince Aetna to change its mind were unsuccessful. When considered in a light most favorable to Fisher, ample evidence supported an emotional distress award of $136,000. And, unfair passion or prejudice did not influence the award.”

As noted above, Aetna employees acknowledged that disability applicants are among the most vulnerable of insurance claimants, that they are ordinarily sick and unable to work, and that they are often in financial difficulties. Thus, the jury could find that insurance bad faith in the context of a disability claim denial is particularly reprehensible.”

Aetna concluded early in the case that Fisher’s claim had merit, but refused to concede that issue until the third week of trial.”

 

Gawrysh v. CNA Insurance Co., 1998 WL 329719 N.D. III, 1998

The Court then noted that CNA believed that Gawrysh’s fatigue was caused by sinusitis rather than CFS and it concluded that such reasoning was shortsighted:
CNA did not deny [claimant]’s symptoms existed or had a debilitating effect, but concluded that because the symptoms could not, with complete certainty, be linked to a specific illness, [claimant] was not totally disabled. The uncontroverted evidence indicates that [claimant]’s symptoms were debilitating and were consistent with chronic fatigue syndrome. Rather than punishing [claimant] for the inability of medicine to specifically pinpoint that cause of her debilitating fatigue, CNA should have hired experts or used its own doctors to examine [claimant] to determine the cause and degree of her fatigue.”

Thus the fact that it was unclear whether Gawrysh’s fatigue stemmed from CFS or chronic sinusitis was an improper basis for denial in the view of the court. Instead, CNA utilized a claims specialist who apparently had no medical training or experience with issues of fatigue to review Gawrysh’s medical records, and that made CNA’s claim denial arbitrary and capricious.”

 

Gaylor v. John Hancock Mutual Life Insurance Co., 112 F. 3d 460 (10th Cir. 1997)

The court held, in light of substantial evidence confirming Ms. Gaylor’s disability, the reason for denying benefits:

reminds us of the doctor, who, when asked for a diagnosis, responds, ‘we won’t know for sure until the autopsy.’ Gaylor at 467.

The Court held that Ms. Gaylor presented enough evidence to establish her disability. The court went on to hold these doctors, “did not use a crystal ball to conclude that Ms. Gaylor was disabled; their opinions were based upon clinical, physical examinations. The verification requirement must be treated as evidentiary in nature. Medicine is, at best, an inexact science, and we should not disregard the great weight of evidence merely because objective laboratory diagnostic findings either are not yet within the state of the art, or are inconclusive”.

 

Godfrey v. Bellsouth Telecommunications, Inc., 11th Circuit Court of Appeals, No 95-6480

An ERISA case decided under the arbitrary and capricious standard. The claimant had fibromyalgia, lumbar disc syndrome, rotator cuff disease and severe pain. The court was critical of the defendant’s rejection of clear medical evidence and ignoring the side effects of medication Godfrey took for her condition.

 

Irwin v. Shalala 840 F. Supp. 751 (D. Or 1993)

“it is sufficient to note that CFS has been recognized by several courts as a legitimate basis for an award of Social Security Disability benefits providing the patients complex is sufficiently disabling.”

The Federal Court stated, “a disability claimant need not vegetate in a dark room in order to be deemed eligible for benefits nor should an otherwise eligible claimant be penalized for attempting to maintain some sort of normalcy in her life and a modicum of independence ..The critical issue in a disability case is the claimant’s capacity for work activity on a regular and continuous, ongoing basis…

One of the more perplexing aspects of CFS is that sufferers often report that their condition varies considerably from day to day. One day they can function reasonably well while on another day they many be unable to get out of bed.”

 

Johnson v. Trustees of the Western Conf. of Teamsters Pension Trust Fund, 879 F. 2d 651, 654 (9th Cir. 1989)

Held that “trustees abuse their discretion if they….construe provisions of [a] plan in a way that clearly conflicts with the plain language of the plan”

 

Ladd v. ITT Corporation/MetLife, US Seventh Circuit Court of Appeals, No. 97-4138, June 22, 1998

Metlife encouraged and assisted Ladd in applying for and being awarded Social Security Disability Insurance (SSDI) benefits then turned around and denied her claim with them. This case is within the doctrine of “judicial estoppel –that if a party wins a suit on one ground, it can’t turn around and in further litigation with the same opponent repudiate the ground in order to win a further victory.”

 

Lang v Long Term Disability Plan of sponsor Remote Technology, Inc, and Standard Insurance Company
No. 96-56080, court of appeals for the Ninth Circuit, D.C. CV-95-351-MLH Brown, 898 F2d at 1561

"Because an insurance company pays out to beneficiaries from its own assets rather than the assets of a trust, its fiduciary role lies in perpetual conflict with its profit-making role as a business.’” “once the beneficiary comes forward with evidence that the fiduciary may have acted in its own self-interest, a more careful review must be undertaken, We explained that: (IND) principles of trust law require us to act very skeptically in deferring to the discretion of an administrator who appears to have committed a breach of fiduciary duty…””the plan bears the burden of rebutting the presumption by producing evidence to show that the conflict of interest did not affect it decision to deny or terminate benefits.”

Ambiguities in ordinary insurance contracts are construed against the insurance company.”“The rule known as the doctrine of contra proferentem, requires us to adopt the reasonable interpretations advanced by Lang, i.e., that the phrase ‘mental disorder’ does not include ‘mental’ conditions resulting from ‘physical’ disorders.”

 

Lantow v Chater, No. 95-5262 (N.D. Okla. October 8, 1996

negative test results or the absence of an objective medical test to diagnose fibromyalgia cannot support he conclusion that claimant does not suffer from a potentially disabling condition.”

 

Lewis v. K-Mart, Lewis v Aetna Life Insurance Co, 1997 WL 671815 (Federal District Court E.D. Va. October 24, 1997)

Court overturned 2 year disability limits” “in order to justify terminating Mr. Lewis’ benefits [after 2 years], K-Mart would have to show that its lesser plan for mental disabilities was based on ‘sound actuarial principles,’ and that K-Mart had filed to show that.”

In this EEOC/ADA action the court ruled that Lewis had a cause of action against his former employer, the benefit plan sponsor and against the insurer, for providing benefits that discriminated against persons suffering from mental disabilities. The court agreed with the plaintiff’s arguments that such a ruling was more consistent with both the statutory language of the ADA and the Act’s goal of eliminating disability discrimination. Thus, the court concluded, “Both a decision to deny coverage on the basis of a mental disability and to provide inferior coverage for mental disabilities target the mentally disabled for inferior treatment.

 

Marshall v. Sullivan, 914 F2d 248 (4th Circuit 1990)

The Court found that the administrative law judge inappropriately ignored reports of treating physicians. The court stated “whatever the name (CFS), the disease exists.”

 

Mitchell v. Eastman Kodak Co., 113 F.3d 433(3rd Cir. 1997)

The Mitchell Court found that the undisputed evidence in the claim file showed that as of the date of disability, ‘Mitchell’s chronic and unpredictable fatigue and loss of concentration made it impossible for him to sustain regular paid employment.” Id. at 440.

It further stated that: “Because the disease, although universally recognized as a severe disability has no known etiology, [citation omitted], it would defeat the legitimate expectations of participants in the Kodak Plan to require those with CFS to make a showing of such etiology as a condition for eligibility for LTD benefits. Thus is 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.”

Despite its acceptance of the sufficiency of the medical evidence as to the CFS diagnosis, however, the Mitchell court took great care to point out that Kodak failed to offer any expert reports or other evidence to counter Mitchell'’ proof and instead choose to merely argue about its alleged insufficiency. Id. at 1054.

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 community that ‘there is no dipstick” laboratory test for Chronic fatigue Syndrome.” “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.

 

Mongeluzo v. Baxter Travenol Disability Plan, 46 F.3d 938, 941 (9th Cir. 1995)

Court discussed 24 month limitation of benefits for “mental illness and functional nervous disorder” in the context of a CFS claim and ruled:
Because of the rule that ambiguities are to be resolved in favor of the insured, if either a cause or a symptom of the disease were physical and caused the disability in whole or in part, then benefits are payable. Mongeluzo at 951.

Because the critical terms of the plan are ambiguous, a genuine issue of material fact exists as to whether Mongeluzo’s symptoms constituted a “mental illness” or a functional nervous disorder.” Consequently we reverse the district court’s grant of summary judgment.

The court noted an immunologist had “submitted an affidavit submitting seven medical articles that conclude that chronic fatigue syndrome is likely caused by an immunological factor and that depression results from the syndrome, rather than the syndrome resulting from depression.” Mongeluzo at 941, ftnt.1.

Also in Sisco, the Tenth Circuit has held “a review of the medical literature in the record demonstrates that a psychological overlay is consistent with a diagnosis of chronic fatigue syndrome; it often develops as a secondary reaction to the physical aspects of the disease”, Sisco at 744, ftnt.1

 

Monroe v. Pacific Telesis Group Comprehensive Disability Benefits Plan, 971 F. Supp. 1310 (C.D. Cal 1997)

The Monroe Court found the denial to be arbitrary and capricious because the plan’s examining physician was not a fibromyalgia expert. Id. at 1315. In addition, the Monroe court felt that there was objective evidence supporting Monroe’s claim in the form of an abnormal sleep study performed by the treating physician and the treating physician’s notation of certain “trigger point” that caused Monroe to suffer. The court further noted that as the treating physician’s report was more detailed than that of the plan’s examining doctor, the denial was arbitrary and capricious because the plan (1) had given more weight to its doctor’s report and (2) had failed to obtain an IME by a rheumatologist as had been urged by the claimant and her treating physician. Id.

 

Mossa v. Provident Life and Casualty Insurance Company, No. 96-5996

Stated that the meaning of the clause "any gainful employment" or "other occupation" clauses in a disability contract does NOT mean "merely a job, paying any wage" but has been interpreted by an "overwhelming majority" of juridictions" as what a policyholder would "reasonably expect" that he would be "a job in which the insured has been trained and has worked during his working life" and that he would be able to earn "a living wage."

The judge said "To hold otherwise would be to ignore the purposes for which individuals purchase disability insurance policies."

(The law firm that represented Moss was Richard J. Quadrino and Eve-Lynn Gisonni of Quadrino & Schwartz in Garden City.)

 

Palmer v. Standard, Portland, Oregon, Civil No. CV 96-1320JE
Palmer v. University Medical Group, 994 F. Supp. 1221, 1233, 1237-1238

Held that denial of welfare benefits due to lack of objective medical evidence was arbitrary and capricious; noted that “merely because we cannot see pain or fatigue on an x-ray, or measure it in a laboratory, does not mean that it is not real.”

(also) the medical opinions of an employee’s doctor carry more weight than those of the insurance company’s doctors.”

 

Postma v. The Paul Revere Life Ins. Co., 1998 WL 641335 at 8 (N.D. Ill 1998)

Held that a fiduciary’s reliance on a doctor’s limited medical review, when presented with contrary evidence from a treating doctor, was indicative of arbitrary and capricious decision making. [Rodriguez, 876 F 2d at 762]

Claimant who could only work four hours a day was presumptively disabled.

 

Rose v. Shalala 34 F 3d (1st Cir. 1994)

Given the uncontroverted evidence that claimant suffered from CFS, blind reliance on a lack of objective findings is wholly inconsistent with the Secretary’s policy in such cases as expressed in the POMS and other pertinent policy statements. The Court continued that although ‘physical examination may be within normal limits,” nevertheless, “individual cases must be adjudicated on the basis of the totality of evidence.” “the absence of definitive diagnostic tests for chronic fatigue syndrome ‘does not constitute substantial evidence to support a finding that claimant did not suffer from the syndrome’”

 

Sansevera v. E.I. Dupont de Nemours, 859 F. Supp. 106, 113 (S.D.N.Y. 1994)

Claim erroneously denied by decision maker not consulting an expert familiar with CFS.
When confronted with an illness that is admittedly difficult to diagnose, it is unreasonable to demand evidence of a specific kind of impairment after experts have concluded that no definitive test for CFS has yet been discovered. Moreover, it is unreasonable to ignore the expert opinions of doctors who, using the best available method of diagnosing the illness, have concluded that Sansevera suffers from a drastically debilitating disease.”

 

Sarchet v. Chater, 78 F. 3d 305 (7th Cir. 1996)

There are no laboratory tests for Fibromyalgia” “Many people are ignorant of the full range of available benefits, or reluctant to undergo arduous administrative proceedings in which they are called liars, until desperation resulting from a personal crisis or as here the cut off of other public funds drives them to seek additional information or to overcome their reluctance to run the bureaucratic gauntlet.”

the tone of the administrative law judge’s opinion suggests that she may have had an unshakable commitment to the denial of this applicant’s claim.”

 

Sisco v. U.S. Department of Health and Human Services, 10 F3d 739, 743(10th Circuit 1993)

Plaintiff could only be penalized for not availing herself of such a test if one existed and she failed to obtain it. There are no such tests available in CFS.”

The National Institutes of Health prints a pamphlet for physicians on CFS and it also prints a pamphlet for the public on understanding Chronic Fatigue Syndrome.”

The administrative law judge cannot substitute his opinion for that of the congress, the Mayo Clinic, the plaintiff’s doctor, and the entire medical community.”

Also in Sisco, the Tenth Circuit has held “a review of the medical literature in the record demonstrates that a psychological overlay is consistent with a diagnosis of chronic fatigue syndrome; it often develops as a secondary reaction to the physical aspects of the disease”, Sisco at 744, ftnt.1

 

Varity Corp. v. Howe, 516 U.S. 489 (1996)

The Supreme Court resolved a split in the federal circuits and held that individual plan participants or beneficiaries can bring claim of breach of fiduciary duty.

In Varity, the Supreme Court had no difficulty holding that a company that acted as a fiduciary and deceived plan participants about their benefits had breached fiduciary duties and was liable in a claim under §502(a)(3). Lower courts have generally held that misrepresentations by a fiduciary that deprive a participant or beneficiary of benefits to which he or she would otherwise have been entitled are actionable under §502(a)(3). See Anweiler v. American elec. Power Serv. Corp., 3 F.3d 986 (7th cir. 1993); Becker v. Eastm Kodak Co., 120 F. 3d 5 (2d cir. 1997).

 

Weiler v. Shalala, CA No 93-12067-JLT, D. Massachusetts, 1996

Held that “(1) administrative law judge (ALJ) should have given controlling weight to opinions of claimant’s treating physicians regarding claimant’s functional limitations; (2) ALJ was prevented from having evidence necessary to fairly evaluate claimant’s subjective complaints of pain and claimant’s credibility by his improper rejection of opinions of her treating physicians; (3) ALJ committed error of law by failing to make individualized assessment of claimant’s ability to handle stress in workplace; and (4) by failing to consider the combination of Weiler’s impairments in making the disability determination.”

Non-examining doctors cannot by themselves trump the findings from treating sources.”

 

Woo v. Deluxe Corp/Hartford Life Insurance, 8th Cir. Appeals, No. 97-2055

Woo suffered from Multiple Sclerosis and Scleroderma, two progressive immunologic diseases which eventually disabled her. Her application for benefits was approved by Social Security Disability. Hartford denied Woo’s benefits because they claimed none of her doctors had specifically stated that she was disabled at the time she resigned from her job.

The Appeals Court found that Hartford not only abused its discretion but has a financial conflict because as plan insurer, Hartford receives direct financial benefit from denying benefits.

The court also found that Hartford “failed to use proper judgment or thoroughly investigate her claim” because they “merely had an in-house medical consultant review Woo’s claim for benefits.”

Hartford failed to use appropriate experts thereby triggering a “less deferential review.”

The court found Hartford’s failure to use proper judgment, when combined with the financial conflict, to be egregious conduct.” Apparently Ms. Woo’s main problem was that she was in denial about the seriousness of her problems and so even though she resigned from her position in Nov. 1993, she did not submit a claim for benefits until March 4, 1995. However, despite her valiant efforts to deny her diseases and her wish to improve, all of her symptoms had been documented in her medical records prior to her resignation by her treating physicians. They had just not specifically stated that she was disabled.