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Jefferson Pilot ordered to pay disability benefits to clinical director suffering from fibromyalgia, chronic fatigue and depression

Annette Engel was employed with Harborcreek Youth Services as a Clinical Director, where she performed duties such as providing leadership and vision, developing proposals, overseeing interviews and recruits of other clinicians, consultation and more.  On September 5, 2007, Mrs. Engel applied for long term disability benefits under her employer’s plan with Jefferson Pilot (aka Lincoln National), claiming fibromyalgia, chronic fatigue, stress, and depression resulting from working long hours.

Mrs. Engel submitted her long-term disability claim with medical records from Dr. Brenda Stringer of the Fibromyalgia and Fatigue Centers, and Dr. Christie Ray,  Mrs. Engel’s primary care physician.  The medical records included information on treatment for fatigue, headaches, stiffness and soreness, as well as inability to sleep, chronic fatigue, immune dysfunction syndrome, fibromyalgia, hyperthyroidism and depression.  On September 9, 2007 Dr. Ray submitted an attending physician’s statement outlining the probable Fibromyalgia as well as stating that Mrs. Engel, “was unlikely to make a full recovery.”

On October 30, 2007, Jefferson Pilot Financial Insurance Company denied Mrs. Engle’s claim, stating, “The medical documentation contained in your claim file does not support disability as defined by this policy.  You were diagnosed with Fibromyalgia, chronic pain, migraine headaches, and syncope.  You had complaints of fatigue, poor sleep, pain and passing out.  According to the medical records, on file your pain level as of 8/29/2007 was 3/10, and as of 8/22/2007 you were getting six hours of uninterrupted sleep.  It was also indicated that you could lift up to 25 pounds. If you disagree with our decision, you may appeal this determination by following the steps outlined below.”

On December 3, 2007, Mrs. Engel appealed Jefferson Pilot’s denial, writing a letter that described in-depth her suffering, from short term memory problems, concentration problems and migraine headaches to severe depression and waking up without feeling rested.  She also stated that Jefferson Pilot had misunderstood her doctor’s notes, because she had not experienced a 3/10 pain since the Fibromyalgia started.  Her doctor confirmed this stating that the patient’s pain was much higher than a 3/10.  Mrs. Engel forwarded results from a mental evaluation as well, completed by Dr. Glenn Bailey on December 7, 2007 which stated the applicant’s “claimed eligibility” was the result of “fibromyalgia, chronic fatigue syndrome, migraines, [and] major depression.”

On February 4, 2008, the medical records were reviewed by Jefferson Pilot’s RN Joyce Mumm, who claimed that there was not enough medical evidence in the records to support Mrs. Engle’s disability claim.  The disability insurance company, on Mumm’s advice, denied Mrs. Engel’s claim once again.  On April 10, 2008, Mrs. Engel appealed again, including additional medical support from Dr. Nossen Goldfarb of the Fibromyalgia treatment centers, stating, among other things, that “I can equivocally state that she is currently incapable of fulfilling these duties and clearly lacks the stamina to work on an ongoing full-time basis. Her constant state of pain, exhaustion and lack of mental clarity make these activities difficult if not impossible for her to perform.”

Updated medical records were sent to Jefferson Pilot, outlining more of the same problems as before, along with new evidence of a possible past Chlamydia infection and more.  Jefferson Pilot referred the claim to a rheumatologist, Dr. Payne, who reviewed the case and found that there was not enough medical evidence to support disability.  After a series of back and forth statements by reviewing doctors, Jefferson Pilot Financial Insurance Company once again denied Mrs. Engel’s claim.

After two prior denials from Jefferson Pilot, Mrs. Engel filed a lawsuit in the United States District Court for the Western District of Pennsylvania.  After hearing the evidence on both sides, Judge McLaughlin ruled, stating, “For the foregoing reasons, I find that the Defendant’s rejection of benefits in this case was not a principled exercise of its discretion but was arbitrary and capricious.” Judge McLaughlin further stated, “Although Defendant requested a copy of the Plaintiff’ job description, it did not give meaningful consideration as to how the Plaintiff’s chronic fatigue, as well as memory and concentration problems, would impact upon her performance.”

The court also noted that Jefferson Pilot’s medical experts did not address Mrs. Engel’s physician’s repeated claims that she suffered from severe, chronic and debilitating memory and concentration problems, which would prevent her from performing her job or any job correctly.