Disability company ignores evidence of disabling back pain and Federal Court reverses disability benefit denial

Once again we look at one of those cases that prove how important it can be to appeal the decision of a District Court. Suzanne Lee had been an employee of BellSouth for almost 10 years. She was diagnosed with chronic pain in October 2003 after she was diagnosed with degenerative disc disease in her back. She continued to work until January 18, 2005, when her pain became so severe that she could no longer sit for longer than 1-1/2 hours at a time, and could not stand or walk for more than 15 minutes.

She applied for short-term disability benefits under the plan that she participated in as a BellSouth employee. BellSouth employed Broadspire Services, Inc. to evaluate her claim. Despite the fact that she provided documentation from over five physicians supporting the existence of her condition and her disability from it, after sending her file to two separate physicians for a peer review, Broadspire determined that she was ineligible for benefits. For a pre-lawsuit history of this case please read our article Seven pieces of medical evidence and disability company still denies claim for lack of “objective evidence”.

After her ERISA appeal of the decision was unsuccessful, Lee filed an ERISA lawsuit against BellSouth for wrongful denial of short-term and long-term disability benefits. The District Court upheld BellSouth’s denial of benefits under the arbitrary and capricious standard of review. It determined that BellSouth had reached a reasonable conclusion based upon the evidence and the wording of the BellSouth Short-Term Disability Plan.

Disability Lawyer Represents Client in Appeal of District Court Decision

Because BellSouth plainly granted Broadspire discretion to determine whether Lee was eligible for short-term disability benefits, the Court of Appeals agreed that the standard of review chosen by the District Court was the correct one. This meant that the question to be answered was “Did Broadspire reached a reasonable decision in light of the evidence in the administrative record.”

The short-term disability plan stated that Lee would be entitled to disability benefits if she suffered from “a medical condition supported by objective medical evidence, which” made her “unable to perform any type of work as a result of a physical or mental illness or an accidental injury.”

Reading the terms of the plan as any ordinary plan participant would understand them, the court concluded that “any type of work” referred to not only her regular job with or without accommodations but any other jobs, regardless of availability, with or without accommodations or temporary modification of duties.

The court understood the plain reading of the plan to require proof that a medical condition existed, but that it did not require “objective medical evidence” that Lee was disabled. Rather, the Court understood the plan to require Lee to support her medical condition by objective medical evidence. If Lee had done this, only then would it be appropriate to consider whether the objective evidence supported her disability.

Court Gives Definition Of Objective Medical Evidence

The Courts have long recognized laboratory test results, MRIs, CAT scans and functional impairment tests as objective medical evidence. Lee’s medical records contained examples of any of these objective medical tests. The court recognized that there is a “subjective” aspect of pain which cannot be measured quantifiably. Frequently the only evidence available is the “subjective” opinion of a physician as he/she interacts with the patient.

In Mitchell v. Eastman Kodak Co., the Court recognized that there are no laboratory tests for chronic fatigue syndrome, yet the disease is almost universally recognized as a severe disability. Because there is no etiology to explain the syndrome, the court recognized that requiring a claimant with CFS to show clinical evidence in order to prove its existence would defeat the legitimate expectation of a plan participant that disability benefits could be collected for this diagnosis.

The Court of Appeals noted that this condition is usually diagnosed through long-term clinical observation. Lee’s medical record reflect the long-term clinical observations of numerous treating physicians. In Oliver, the Court found that the disability insurance plan had acted arbitrarily and capriciously when it refused to recognize the only medical evidence that Oliver was capable of producing, reports from multiple physicians stating that his reports of pain were consistent with their diagnosis as well as EMGs, nerve conduction tests and an MRI.

Court Finds More Than Sufficient Medical Evidence in File

In Lee’s case, she had submitted more than enough evidence to support her claims. Her file contained reports from five treating physicians, all confirming the presence of debilitating chronic thoracic back pain. Her physicians noted that she required so much pain medication that she functioned in a state of “seriously limiting sedation.”

The Court found that there was no wording in the short-term disability plan that excluded pain related disabilities from coverage. At the same time, the Court has recognized the right of disability plans to require objective evidence to support the purported limitations created by pain syndromes. In this case, Lee had presented considerable evidence to support her inability to perform in a sedentary position. She had been unable to complete a functional impairment test in January 2004. Her “[f]unctional motions were insufficient to assess lifting” and her “[g]ait was aberrant and appeared more as a shuffle as opposed to attempt to reduce stance on either side” according to the tester.

Lee’s case was similar to Oliver. The disability insurance plan had provided no evidence to dispute the physician’s observations and evaluations of the tests which have been performed. And the disability insurance plan had failed to provide clear guidance as to what additional testing Lee needed to undergo to provide the additional “objective” evidence the disability plan was looking for.

Court Finds That Peer Reviews Were Faulty

BellSouth had relied on peer reviews which chose to discredit the opinions of physicians who had seen Lee over the space of several years. It was arbitrary on the part of the physician to determine that information in the doctor’s statements and reports were merely a recital of information supplied by Lee. Rather much of the information provided by her treating physicians clearly reflected objective observations.

For example, one physician had been extremely alarmed when he saw his patient. He noted that she could hardly talk or breathe smoothly because the muscle spasms she was experiencing were so severe. He observed that she could barely walk and was so unsteady that he personally assisted her into the office, and almost called his nurse to assist in as well. This was clearly an objective observation.

These flawed peer reviews led BellSouth to conclude that Lee’s medical condition did not render her “unable to perform any type of work.” Yet, neither of the two physicians Broadspire sent her file to addressed the fact that she could not sit for more than 1-1/2 hours. Nor did they consider that she could only do this when she was under heavy sedation. They also fail to recognize that mental fog caused by her heavy medication would also make it very difficult to perform a job. They also fail to address the fact that Lee’s physicians had observed that she was unable to move, speak, or breathe freely.

Court Finds Claimant Clearly Proved Disability

The court found that after reviewing the medical evidence provided by Lee and her treating physicians, she was clearly disabled under the short-term disability plan, because her medical condition made it impossible for her to perform “any type of work” as defined by the plan.

Lee had been eligible for short-term disability benefits from the time of her application on January 25, 2005. Despite the fact that the last peer reviewer had concluded that Lee met the short-term disability plans definition of disability between May 16, 2005 and July 19, 2005, the day he reviewed her file, Lee had never received any benefits, because the plan required her to be a current employee of BellSouth and she had been laid off on May 4, 2005 for failing to return to work after she exhausted her Family and Medical Leave benefit.

The Court found that Lee had been wrongfully denied short-term disability benefits, thus she was also wrongfully terminated for her position at BellSouth. The SD Plan benefits excused absence from work for up to fifty-two weeks “as long as the Participant remains continually Disabled and otherwise meets the terms and conditions for Benefit payment.”

Court Finds BellSouth Decision Arbitrary and Capricious

The three Federal appellate judges reviewing this case found that BellSouth’s decision was not reasonable in light of the evidence. Summary judgment for BellSouth needed to be reversed in its entirety and the case shall be sent back to the District Court for reevaluation.

While the court of appeals had clearly found that she was entitled to benefits from January 25, 2005 through July 19, 2005, the District Court needed to evaluate whether Lee was also entitled to short-term disability benefits from July 19, 2005 through the end of the short-term disability term on January 25, 2006. The District Court would also have to consider whether Lee would then be entitled to the long-term disability benefits that would have begun a January 26, 2006.

This case once again highlights the value of pursuing an appeal when a district court makes a decision favorable to the disability insurance plan. So often, three judges are better than only one. The three perspectives this gives to interpreting the evidence increases the odds that a correct and favorable decision for the disability claimant will be achieved.