We typically see cases where claimants provide the disability insurance company with medical records that reflect substantial subjective complaints, such as pain, fatigue, headaches, but lack objective evidence – positive findings on MRIs, X-rays or lab work. The disability insurance companies commonly deny claims on the basis of there being no objective evidence.
However, a recent case out of Connecticut was denied on the opposite grounds. In this case, the claimant, Mr. H, provided objective evidence of his injury that could not be disputed: an MRI of his lumbar spine which revealed a herniated disc. Hartford determined that there was not enough subjective evidence in the records to show that the claimant’s herniated disc actually caused any impairments or caused an inability to work his own, or any occupation. The Court ruled in favor of Hartford, concluding that Hartford’s decision to deny disability benefits was based on substantial evidence and was not arbitrary or capricious.
Mr. H’s Claim and the Administrative Appeal
Mr. H initially was approved for long term disability benefits due to a mental illness. As such, he would only receive benefits for a period of 24 months due to his Plan’s mental illness limitation. Less than a year before his benefits were due to expire, Ms. H and his treating physicians began submitting information to Hartford which documented his complaints of low back pain. The records indicated that an MRI revealed evidence of a herniated disc in his lumbar spine. Mr. H underwent 2 epidural steroid injections which did not help his pain and he was referred for physical therapy. Mr. H did not attend physical therapy and claimed he could not afford the co-pay for the physical therapy sessions. He continued to report back pain rated 7 out of 10 on a 1 to 10 scale, and he was referred for a surgical consultation. The spine surgeon diagnosed Mr. H with a herniated disc, lumbar spondylosis and radiculitis, and recommended he undergo surgery. The surgeon informed Mr. H that the surgery would significantly reduce his pain, but Mr. H chose not to have surgery.
As part of its investigation into Mr. H’s claim for disability based on his physical condition, Hartford requested that Mr. H undergo an Independent Medical Examination and sign an authorization for such. Mr. H refused to sign the authorization or undergo the IME on the basis of the sensitive nature of his psychological treatment for his mental health conditions.
Hartford denied Mr. H’s claim for continued benefits based on his back condition and stated that, “while you have complaints of back pain with some findings, it is not documented to be of a severity to preclude you from performing a sedentary occupation with the ability to change positions as needed.”
Mr. H appealed the benefit denial and argued that Hartford already had sufficient information in its possession to warrant a continuation of his benefits, even without the IME. His treating physician submitted a letter stating that Mr. H “continued to be medically disabled due to his chronic low back pain.” Mr. H submitted an APS from his physician which indicated that he could only sit, stand and walk for less than an hour at a time each, less than two hours each in a day. The physician also concluded that Mr. H could not perform a sedentary occupation and that his prognosis was poor without surgical intervention.
In its appeal review, Hartford utilized 2 independent physician consultants to review Mr. H’s medical records: a Physical Medicine and Rehabilitation physician (PM&R), and an Orthopedic Surgeon. Both physician consultants found the fact that Mr. H chose not to undergo surgery indicative that Mr. H was not disabled as he claimed. The PM&R physician noted that, “the lack of follow up regarding surgery when offered, without an explanation or contraindication, suggests an ability to pursue functional activities without surgery.” The Orthopedic Surgeon found that, “[t]he claimant does have a legitimate medical problem, that is, a herniated lumbosacral disc on the left [but] for some reason he has chosen not to have the surgery recommended and this could be from a variety of reasons… One obvious conclusion, however, is that the pain and discomfort he was experiencing is not sufficient for him to seek a surgical remedy.” It was further noted that, “patients are seen all the time with ruptured disc. If they are hurting badly enough, they have surgery and if not, they are able to perform sedentary work for eight hours with work accommodations which will accommodate the disc herniation.”
The physician consultants also noted that Mr. H’s treating physician completed an APS that stated Mr. H could walk, stand and sit for a total of a 6 hour work day, and that the medical records reflected Mr. H had a normal gait, was able to climb on the exam table without assistance, was “physically… very fit”, and “in good physical condition except for his back.” The physician consultants opined that Mr. H could perform his sedentary occupation with a 10 pound lifting restriction and with a 2-3 minute stretch break every hour. Based on this information, Hartford upheld its denial of continued disability benefits.
The ERISA Lawsuit
Mr. H filed an ERISA lawsuit against Hartford and argued that Hartford’s denial of his claim was arbitrary and capricious because 1) Hartford was acting under a conflict of interest; and 2) Hartford’s determination was unreasonable and not supported by substantial evidence because Hartford ignored or misstated the opinions of his treating physicians and relied on unsupported conclusions of the physician consultants.
The Court immediately dismissed Mr. H’s claim that Hartford was acting under a conflict of interest and found that no conflict existed. For his second allegation, Mr. H argued that Hartford ignored evidence of his complaints of debilitating pain, such as his treating physician’s opinion that Mr. H’s “constant, persistent back… pain could impair his concentration and cognitive abilities if he is required to work a sedentary position 8 hours per day 40 hours a week,” and the indication that he reported constant pain at all times rated 6 to 8 on a scale of 10. Mr. H also points to the APS that indicated objective evidence such as the positive MRI, tenderness and decreased range of motion on physical examination.
The Objective Evidence Does Not Support Disability Due To Lack Of Substantial Subjective Evidence
The Court cited to the well-established rule that, “administrators are not obliged to accord special deference to the opinions of treating physicians”, and that, “it [is] not unreasonable for the administrator to conclude that the only material reason the treating physicians were reaching their diagnoses was based on their acceptance of plaintiff’s subjective complaints: an acceptance more or less required of treating physicians, but by no means required of the administrator.”
The Court further noted a case very similar to Mr. H’s, wherein the plaintiff had a positive finding on MRI and a report from her doctor that her chronic pain was disabling and that she was unable to work. In that case, the Court upheld that “the purely objective evidence indicated that plaintiff should be able to work an eight-hour day, provide she changed positions and periodically stood and walked, rather than just sit.”
In Mr. H’s case, the Court pointed out that Hartford considered and rejected his subjective pain complaints because it was determined that the pain and discomfort he was reporting was not enough to cause him to undergo the surgical procedure that was recommended to alleviate his pain. Mr. H argued that the reason he did not undergo the surgery was because he could not afford it. However, the medical records only reflected his statement that he could not afford the physical therapy co-pay, not that the reason he chose not to undergo surgery was lack of finances. The Court also noted that the medical records reflected that Mr. H had very little treatment for his back injury and that nearly one year passed before he had his first epidural steroid injection. The record further documented that Mr. H was very physically fit and muscular, which is contrary to a person who is alleging an extended period of functional incapacity due to severe pain.
Mr. H also argued that it was inappropriate for Hartford to rely on the opinions of the physician consultants, who only reviewed his medical records, without having conducted a physical examination of Mr. H. The Court rejected this argument as it is well-established that an administrator is not required to have a claimant physically examined and that it is customary for administrators to rely on the opinions of independent Board-certified physicians in the evaluation of ERISA claims. Mr. H did not point to any medical evidence that gave cause to question the conclusions of the physician consultants and the Court specifically notes that Mr. H refused to sign Hartford’s authorization for Mr. H to undergo an IME.
The Court determined that Hartford’s decision to deny Mr. H continued long term disability benefits was based on substantial evidence and was not arbitrary or capricious.
Attorneys Dell & Schaefer did not represent Mr. H in his disability claim, appeal or lawsuit. If you have questions regarding your claim for disability benefits, or if your disability claim has been denied, feel free to contact Disability Attorneys Dell & Schaefer for a free consultation.
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