Aetna denial of long-term disability benefits for chronic fatigue syndrome upheld by Court

Physician’s Failure to Fill Out Functional Limitations Paperwork Costs Man Rightful Benefits

A supporting physician is essential for any claimant to receive long-term disability benefits. However, a treating physician must do far more than just diagnosis a disabling medical condition. The decision rendered by the U.S. Court of Appeals, Seventh Circuit in Williams v. Aetna Life Insurance Company continues to have an impact on long-term disability decisions in U.S. Courts even though it has been over two years since Lee K. Williams lost his appeal against Aetna Life Insurance Company (Aetna) and The Sysco Corporation Group Benefit Plan (Plan). Williams’ unsuccessful attempt to secure a Court reversal of his long-term disability denial for chronic fatigue syndrome (CFS) continues to shape the strategies of disability attorneys as they help their clients perfect their claims for this non-objective ailment.

Williams, who was 48 at the time of the court decision, had been a truck driver for Sysco since November 1994 until his CFS made it too exhausting to continue working on July 26, 2002. His job wasn’t completely sedentary. Despite the fact that he spent many hours on the road, he helped unload the deliveries. This meant he might have to lift 100 lbs., climb ladders, kneel, twist and stoop for up to two hours of his day. Aetna considered these occasional work responsibilities. He spent up to another four hours of the day lifting up to 50 lbs., climbing stairs, pushing, pulling, reaching, grasping, sitting, standing, walking, and using his fine and gross manipulations skills. Aetna considered these frequent job required tasks. Finally, the continuous job requirements, which could occur throughout his eight-hour day, included lifting up to 20 lbs., carrying up to this amount of weight and bending.

As a participant in the Sysco Corporation Group Benefit Plan, Williams expected to be able to collect benefits after he became ill on July 26, 2002 and had to be admitted to the hospital for his symptoms – fatigue, shortness of breath, dizziness and cough. Even after his release, his symptoms continued, so he underwent a series of tests to determine the cause of his symptoms. Dr. John Sorin, an immunology and CFS specialist at Northwestern Hospital, ruled out other conditions before he reached the conclusion that Williams had CFS.

In February 2003, Williams applied for long-term disability benefits under the Aetna Disability Plan. Dr. Sorin submitted an Attending Physician Statement informing Aetna that Williams had been diagnosed with CFS. Dr. Sorin expressed his opinion that Williams had a Class 5 impairment – unable to perform even minimal sedentary activities.

Aetna asked Sysco, in March 2003, to provide a physical demands analysis for Williams’ truck driving position. Armed with this information, Aetna sent Williams’ application to Dr. Brent Burton for review. Dr. Burton’s evaluation stated that the medical data in the file failed to provide documentation that Williams had a diagnosable medical condition that accounted for his subjective symptoms of fatigue. The data from physical examinations showed no evidence that Williams had lost his range of motion, strength, coordination or ability to feel. Dr. Burton also found that none of the information in the file indicated that Williams’ impairment was significant enough to prevent him for working as a truck driver.

On May 12, 2003, Aetna notified Williams that the disability insurance plan was denying his claim because to quote Dr. Burton “[T]he medical data in this case do not provide any documentation that Mr. Williams has a diagnosable medical condition that explains his subjective symptom of fatigue. The physical examination data do not reveal evidence of significant loss of range of motion, strength, sensation, coordination, etc., to justify discontinuation of workplace activities. There is no data to indicate that Mr. Williams has sufficient impairment to render him unable to work in his usual occupation as a truck driver.”

Physician fails to complete residual functional capacity questionnaire completely.

Williams appealed Aetna’s decision. Dr. Sorin sent the long-term disability Plan administrator a note on May 19, 2003 stating that he was treating Williams for CFS. In his opinion, even though Williams was showing signs of improvement, the truck driver was still unable to resume work. Aetna asked the doctor to fill out a CFS residual functional capacity questionnaire. Dr. Sorin returned the questionnaire on August 11, 2003, but it was not filled out completely.

While Dr. Sorin did fill out the section dealing with how Williams’ fatigue constantly interfered with his ability to concentrate and focus, he failed to provide explanations to support some of the other conclusions he had drawn. When asked to provide his estimate for how long Williams could perform certain activities, he provided partial answers. For example, when asked how many hours Williams could sit or stand at one time, the doctor wrote “unknown” in the margin. He stated that Williams could lift 10 lbs. occasionally, but failed to indicate if he could lift any higher weights. He stated that Williams had significant limitations when repetitive reaching, handling and fingering were involved, then later stated that he had not tested Williams to evaluate how long Williams would be able to perform these activities each day.

Disability attorney files ERISA appeal of Aetna disability denial decision.

Williams’ disability attorney wrote a formal appeal letter to the disability insurance company on September 10, 2003. Aetna upheld its denial of disability benefits on January 9, 2004, after considering the additional information supplied by Dr. Sorin. The denial pointed specifically to the Dr. Sorin’s report that had stated several times that Williams had not been tested for functional limitations for the very activities he was claiming he could no longer perform. The disability insurance Plan stated clearly that without this evidence, Aetna could not reverse its decision. His file was closed. Williams’ attorney should have considered having his client undergo a functional capacity evaluation.

Disability attorney advises Aetna that his client was approved for SSDI and files ERISA lawsuit

On July 28, 2004, the disability attorney requested a copy of Williams’ claim file. He also notified Aetna that the Social Security Administration had deemed Williams disabled. When this information failed to prompt Aetna to reverse its denial of benefits, Williams filed suit against Aetna and the Plan under the Employee Retirement Income Security Act (ERISA) section § 1132(a)(1)(8). The District Court ruled in favor of Aetna and the Plan on September 28, 2004.

Disability attorney files appeal of District Court decision.

Williams’ disability attorney filed an appeal with the U.S. Court of Appeals, Seventh Circuit. In evaluating the correctness of the District Court’s decision, the judges hearing arguments had to follow carefully the guidelines established by ERISA. Because the long-term disability Plan gave Aetna discretion to determine whether Williams was eligible for benefits and to interpret the terms of the Plan, the Court of Appeals had to consider Aetna’s decision under the arbitrary and capricious standard, just as the District Court had. The judges also could only listen to arguments that had been presented before the District Court.

Because Aetna’s decision fell under the arbitrary and capricious yardstick, the Court only had to determine whether Aetna’s decision was reasonable in light of the evidence in the records kept of Williams’ claim. His disability attorney argued that Aetna’s decision was not supported by the record.

• The disability attorney claimed that the Plan had denied Williams’ application because his subjective symptoms of fatigue could not be confirmed by medical diagnosis. This was in direct violation of the findings of Hawkins v. First Union Corp. Long-term Disability Plan. The Court found that after Williams’ appeal, Aetna agreed that he did indeed have CFS, but upheld its denial of benefits based upon the lack of evidence supporting how much the CFS impacted his functional abilities.
• The disability attorney argued that Aetna’s use of Dr. Sorin’s incomplete questionnaire as reason to deny benefits was arbitrary and capricious. The Court found otherwise. Because Dr. Sorin failed to explain how he could determine that Williams had significant functional limitations when he wrote “unknown” and “untested” as an answer to different questions designed to evaluate the performance abilities of his patient, the Court found that his entire evaluation failed the test of credibility. The Plan’s denial of benefits based upon Dr. Sorin’s failure to provide clear and accurate information could not be faulted.
• The disability attorney alleged that Aetna had denied Williams a full and fair review. The Court disagreed. While the Court would have preferred that the final denial letter had not quoted Aetna’s physician’s conclusions verbatim, the denial letter still contained a sufficient summary of the other information in Williams’ file and a reasonable breakdown of the reasons the claim was being denied – including the fact that Dr. Sorin’s questionnaire failed to support Williams’ disability.
• The disability attorney claimed that Aetna’s refusal to give credit to Dr. Sorin’s findings demonstrated an arbitrary and capricious decision by the disability insurance company. The Court refused to fault Aetna’s conclusion that Dr. Sorin had failed to provide sufficient support for Williams’ functional restrictions.
• The disability attorney argued that Aetna had violated its own internal procedures when it failed to obtain additional medical information when Dr. Sorin’s findings and Dr. Burton’s conclusions differed. The Court also found this argument meritless. While the two reports disagreed on the CFS diagnosis, the denial was not based on this fact, but on the lack of proof that Williams was functionally impaired.
• The disability attorney alleged that Dr. Burton’s opinion was inherently biased and unreliable because he was the Plan’s medical consultant, making Dr. Sorin’s opinion of greater weight. The Court looked to Black & Decker Disability Plan v. Nord, where the Court expressly held that plan administrators are not obliged to accord special deference to the opinions of treating physicians, and Davis v. Unum Life Ins. Co., where the Court refused to consider the argument that in-house doctors have an inherent conflict of interest. The Court also found Dr. Sorin’s report failed to demonstrate internal reliability.
• Finally, the disability attorney argued that Aetna had failed to credit the Social Security’s determination that Williams was disabled by his CFS. The Court recognized the differences between Social Security Disability and ERISA benefit plans and found the argument without merit because Aetna did not require Williams to apply for Social Security disability benefits in order to retain his rights to long-term disability benefits under the Plan.

In conclusion, the Court found that Williams’ disability attorney had failed to present any arguments that proved Aetna had made an arbitrary and capricious disability benefits denial. The Court of Appeals affirmed the decision of the District Court and granted summary judgment in favor of the Sysco Corp. Group Benefit Plan.

The primary lesson to be learned from this case is the value of medical information that clearly supports a disability attorney’s client’s disability claim. Treating physicians are not trained to answer insurance company medical questionnaires. A treating physician’s failure to document restrictions and limitations will always jeopardize a claimant’s disability claim. The insurance company are trained that diagnosis does not mean disability. As result, a claimant’s medical records must clearly document restrictions and limitations. If an experienced disability attorney becomes involved in a claim he/she should be able to identify this type of issue, and possibly save his/her client from a long, yet unsuccessful legal process.