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Federal District Court Overturns Hartford’s Denial of Long Term Disability Benefits

Attorney Stephen JessupAuthor: Attorney Stephen Jessup

In the recent decision of Tobin v Hartford Life & Acc. Ins. Co. a Michigan Federal District Court overturned Hartford’s denial of long term disability benefits to a former Disney employee suffering from Fibromyalgia. The Court noted in its opinion that Hartford’s requirement of objective evidence of the diagnosis of Fibromyalgia was arbitrary under applicable case law in Michigan and that in denying her claim for benefits Hartford failed to adequately review Tobin’s medical records/claim to determine how her diagnosis of Fibromyalgia restricted her from working.

Many disability insurance claims resulting from Fibromyalgia are often denied by insurance companies due to a lack of objective medical evidence to support restrictions and limitations. Note, that this does not always necessarily mean the insurance company stating you do not have a condition, but rather an acknowledgment that you do have a medical condition but there is no evidence as to how the condition impairs your ability to work. However, in Tobin, Hartford denied the claim due to a lack of objective evidence of a diagnosis of Fibromyalgia.

For purposes of pain related disabling medical conditions objective evidence can include diagnostic testing such as MRIs, CT Scans, EMG and Nerve Conduction Studies, X-Rays, etc, as well as blood testing for rheumatological conditions. However, Fibromyalgia is classically known as having no definitive one stop shop test to verify a diagnosis and is often a diagnosis born from testing to rule out other potential medical conditions. In light of this issue with diagnosis many insurance companies attack these claims. Such was the case in the Tobin case.

The Court’s Findings

In denying her claim for disability benefits, Hartford argued that there was no objective proof of her diagnosis of Fibromyalgia and a lack of evidence to support her subjective complaints of pain. In rendering this opinion and as justification for its decision to deny benefits, Hartford pointed to the reviews of its doctors, which indicated the medical records did not reflect evidence of neurological or rheumatological conditions, and that her medical history showed normal tests results. The Court was quick to point out that it should not have been surprising that Tobin’s results didn’t show evidence of other such conditions or that her test history was “normal” as the Sixth Circuit has, “recognized on more than one occasion, however, that fibromyalgia patients generally ‘present no objective alarming signs.”

The Court stated that it was Hartford’s right to require objective proof of functional limitations as a result of her condition but that it was unreasonable to require objective proof of diagnosis. The Court accused Hartford of engaging in the “logical fallacy sometimes called the red herring.” A red herring is an attempt by a proponent to introduce a new issues (one that they are usually prepared to argue) in an attempt to avoid the real issue. In this case, the Court noted that instead of determining whether Tobin was disabled from Fibromyalgia, Hartford instead focused on what she was not disabled by (neurological or rheumatological conditions) as a way to distract from the real disabling condition and by doing so never determined if her Fibromyalgia would be disabling.

The Take Away

This is certainly a strong case for the Plaintiff; however, much of the decision was centered on case specific facts that would not necessarily be universal to all insureds seeking disability due to Fibromyalgia. For instance, the Court took issue with the reports of Hartford’s reviewing doctors for not considering or discussing any potential functional limitations and the fact that Hartford’s doctor was never supplied or completely ignored Tobin’s doctor’s statement of functionality. That being said the Court illustrated and acknowledged an all too common occurrence where a disability insurance carrier relies on an absence of findings or information irrelevant to a diagnosis of Fibromyalgia as a basis of denial.

It is also important to reiterate that the Court agreed it was reasonable to require objective evidence of functional limitations. This is similar to the idea that “diagnosis doesn’t equal disability,” or that having a diagnosis is not sufficient to prove disability and that functional limitations on account of the medical condition are still required to support a claim for disability benefits. It is possible that had Hartford’s denial of benefits been based on a lack of objective evidence of functional limitations due to the Fibromyalgia (as opposed to the diagnosis) that the Court would have upheld its decision to deny benefits.