In our firm’s experience, administrators of ERISA plans (“insurers”) are quick to disregard subjective conditions when evaluating individual claims for long-term disability benefits. Although conditions like chronic pain, stress and fatigue can make it impossible for people to work a full-time job, insurers will regularly discount medical evidence that cannot be measured by an X-Ray, MRI, blood test or other objective measurements. There is good news for claimants, however. In the Sixth Circuit, which includes the federal district courts in Tennessee, courts have repeatedly stated that insurers cannot ignore subjective evidence in support of a disability claim−unless the policy at issue allows them to do so.
For example, in Evans v. Unumprovident Corp. (6th Cir.2006), a claimant applied for long-term disability benefits on the basis that her epileptic seizures prevented her from working at her job as a nursing home administrator. Her treating physician stated that the stress from her job led to the severity and frequency of her seizures. While on medical leave, the claimant’s condition improved. As a result, her treating physician determined that it would be in her best interest not to return to work.
However, the insurer denied the claim finding it unreasonable for the claimant’s physician to opine that a return to work would exacerbate the claimant’s condition. In reaching this decision, the insurer relied heavily on its own physician’s review of the claimant’s medical records, in which that reviewing physician determined that the impact of stress on the claimant’s condition was entirely self-reported and had not been corroborated by medical studies.
Finding that the insurer’s decision was arbitrary and capricious, the Sixth Circuit affirmed the district court’s re-instatement of disability benefits. It also affirmed the district court’s award of past-due benefits and attorney’s fees. In explaining its ruling, the court observed that, while the insurer’s physicians described the plaintiff’s stress as “unverifiable,” her disability policy “does not state that self-reported occurrences are to be accorded lesser significance when considering whether a person is able to work.”
Similarly, in Glenn v. MetLife (6th Cir. 2006), the insurer denied a claim for long-term disability benefits on the grounds that there was no “supportive medical documentation” showing that stress exacerbated the claimant’s heart condition. The Sixth Circuit, however, determined that the insurer’s denial was arbitrary and capricious and overturned a lower court’s decision in favor of the insurer. Similar to its opinion in Evans, the Sixth Circuit found fault with how the insurer disregarded the claimant’s subjective evidence, noting that it was “unreasonable for MetLife to have dismissed stress as an improperly documented, subjective, and irrelevant factor in its disability determination.”
In Cooper v. Life Ins. Co. of N. Am., (2007), the Sixth Circuit noted that insurers can require that claimants “provide objective medical evidence of disability.” That requirement, however, has its limits. As noted by the district court in Zenadocchio v. BAE Sys. Unfunded Welfare Ben. Plan (S.D. Ohio 2013), insurers cannot dismiss other evidence in favor of a claim unless the policy expressly states that any disability be supported solely by objective evidence. In other words, insurers can require that you submit objective evidence of your disability. They cannot, however, discount other evidence, including self-reported symptoms, unless the language in the policy allows them to do so.
Courts take other factors into account when evaluating subjective evidence in support of a claim for long-term disability benefits. First, as the Glenn and Evans opinions make clear, courts are critical of insurers that discount a claimant’s subjective evidence when the claimant’s treating physician supports the claim at issue.
Second, as noted recently by the Sixth Circuit in Shaw v. AT & T Umbrella Ben. Plan No. 1 (2015), an insurer’s “credibility determination” of a claimant’s subjective reports of pain are “troubling” when the insurer merely conducts a file review of the claim, instead of exercising its right under the policy to examine the claimant. Most disability policies allow an insurer to require that the claimant attend an independent medical exam in order for a non-treating physician to evaluate the claimant. If an insurer opts not to exercise this right, and disregards the claimant’s subjective evidence based on merely a file review of the claimant’s medical evidence, courts are likely to find fault with the insurer’s denial of benefits.
As you can probably tell from the discussion above, disability cases are complex. Claimants typically submit a range of evidence in support of their disability, and insurers will look for ways to diminish the importance of that evidence. If your claim for long-term disability benefits has been denied, you should consult with an experienced disability law firm.