Do Courts Require Objective Medical Tests to Support a Fibromyalgia Diagnosis?

In Dana Krysztofiak v. Boston Mutual Life Insurance Co. (Boston), Plaintiff, a registered nurse, was employed as a Clinical Coordination Manager for HomeCare Maryland, LLC. On December 29, 2016, she stopped working due to psoriatic arthritis and fibromyalgia.

At the time, Plaintiff filed a claim for long term disability (LTD) benefits under a Boston Mutual Life Insurance Co., policy. Her claim was approved, and she began receiving benefits on April 13, 2017.

On May 29, 2018, Plaintiff’s benefits were terminated when Boston’s claim administrator, Disability Reinsurance Management Services, Inc. (DRMS) determined she was no longer disabled. When her administrative appeal was denied, Plaintiff filed this ERISA lawsuit in the United States District Court for the District of Maryland.

Plaintiff sought a declaration that she was entitled to reinstatement of benefits that were erroneously terminated, and a declaration that she was entitled to benefits going forward for as long as she remained disabled.

Just before the benefit termination, Plaintiff’s treating physician, Dr. Rehman, reported that psoriatic arthritis was no longer a problem and the reason for the disability was due to Plaintiff’s fibromyalgia. Boston used this doctor’s statement to argue that since her psoriatic arthritis was under control, she did not meet the definition of disability based on fibromyalgia alone.

The Court disagreed with Boston, noting that “the administrative record is replete with descriptions and analyses of Ms. Krysztofiak’s fibromyalgia…”. After reviewing the entire record and briefs of both parties, the Court ruled in favor of Plaintiff, finding that she proved by a preponderance of the evidence that she was disabled from performing the duties of her own occupation; therefore, Boston abused its discretion and acted arbitrarily and capriciously when it terminated her LTD benefits.

Since the issue about whether Plaintiff was disabled past the 24 months when the definition of disability under her policy changed to requiring her to be unable to perform the duties of any job for which she was educated or trained, the Court did not rule on whether she was entitled to future LTD benefits.

Boston Acted Arbitrarily and Capriciously by Requiring Objective Tests Verifying a Diagnosis of Fibromyalgia When Objective Tests Do Not Exist

In order to assess Plaintiff’s condition and decide if she was entitled to LTD benefit, DRMS ordered her to participate in a functional capacity evaluation (FCE) and undergo an independent medical exam (IME) with Dr. Parkerson. Then, Boston hired a physician, Dr. Russell, to review her medical records.

Based on all three of these reports, Boston terminated Plaintiff’s LTD benefits claiming they provided substantial evidence for its decision. In addition, Boston argued that Plaintiff’s “failure to provide ‘objective evidence’ of her claimed limitations means she has not met her burden for demonstrating a disability.”

The Court disagreed, finding issues with each report, and that Boston misinterpreted the law. The Court found that as to each report, Boston abused its discretion by requiring “objective evidence” of fibromyalgia, which is not the same as providing “objectively satisfactory” evidence.

The problems the Court found with Boston’s decision include:

The FCE. The exam included some equivocal statements that could indicate Plaintiff could perform her job duties, but ultimately concluded that she “would not be able to perform the job functions of Clinical Coordinator Manager, due to claimant not being able to perform frequent fingering…”. Boston ignored this conclusion and focused on what it called discrepancies in the report and Plaintiff’s statements about why she felt she was disabled.

The Court questioned how Boston could read that sentence and still conclude that Plaintiff could perform her job duties. The Court also chastised Boston for its attempts to “malign” Plaintiff by calling her a “malingerer” and questioning her credibility.

The IME. Dr. Parkerson who concluded, among other things, that the diagnosis of fibromyalgia is made based on a person’s complaints and the exclusion of other causes of the complaints. He concluded that “fibromyalgia does not present her with any physical limitations or restrictions.” He commented on the “lack of lab tests, or imaging studies that can prove a diagnosis of fibromyalgia.” Dr. Parkerson attributed her complaints of pain to possibly her “bipolar depressive disorder, endocrinopathy, and opioid dependence.”

One main problem the Court found with this report is that the physician was essentially saying that fibromyalgia could never result in disability. Plus, as for opioid dependence, Plaintiff’s treating physicians had already reported that Plaintiff was no longer dependent on opioids.

Medical file review by Dr. Russell

Dr. Russell stuck to Boston’s party line: There was no objective evidence verifying the diagnosis, therefore Plaintiff must not be disabled.

The Court ruled in favour of Plaintiff, holding that “Because Boston Mutual’s denial of disability benefits was neither supported by substantial evidence, nor the result of a deliberate, principled reasoning process, the decision to deny Ms. Krysztofiak benefits was an abuse of discretion…”.

Court Ordered LTD Benefits for Plaintiff’s Inability to Perform Duties of Her Own Occupation

The Court noted it had discretion to award benefits or remand to the administrator, but that remand should be “used sparingly, especially where the evidence shows the plan administrator abused its discretion [citations omitted]”.

Here, the Plaintiff convinced the Court she was disabled from performing the duties of her regular occupation, which under the policy, was for 24 months. The Court noted that since the Plaintiff’s lawsuit only addressed the termination of benefits during the time the definition of disability required her to prove she was unable to perform the duties of her own occupation, it could not “at this time and on this record, determine Ms. Krysztofiak’s eligibility for benefits beyond the now-lapsed 24-month period”.

This case was not handled by our office, but if you have any questions about it, or any other concern about your claim for either LTD or short term disability (STD) benefits, feel free to call one of our disability attorneys at Dell & Schaefer for a free consultation.

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