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Court Orders Aetna to Pay LTD Benefits to Plaintiff Suffering from CFS

In Nancy Devries v. Aetna Life Insurance Company (Aetna) plaintiff worked as First American as a Senior Business Analyst until August 19, 2016. On that day, she stopped working. A few days later, she filed a claim for short term disability (STD) benefits.

Plaintiff was under continuous care of her primary care physician, an immunologist, and a physician’s assistant (PA). She had frequent medical visits, sometimes up to four times a month. All her health care professionals concluded that, based on Plaintiff’s laboratory results, multiple symptoms of muscle aches, sinus problems, sore throat, overwhelming fatigue, and more, that she was likely suffering from chronic fatigue syndrome (CFS).

Her application for short term disability (STD) benefits was approved from August 26, 2016 through November 21, 2016. On January 4, 2017, Aetna informed Plaintiff that her STD benefits ended on December 29, 2016 and that it was evaluating her claim for LTD benefits. Plaintiff apparently appealed the termination of her STD benefits.

A claims examiner who evaluated Plaintiff’s claim for long term disability (LTD) benefits reported that Plaintiff’s records indicated she did not need help with activities of daily living and could drive, walk, and do “exertional exercise classes.” Based on that information, the examiner concluded that she could perform “in excess of sedentary work requirements.”

Based on that report, Aetna informed Plaintiff by letter dated March 9, 2017, that it had denied her LTD benefit clam “because the information we received isn’t enough to show that you aren’t able to work…” The letter informed her of her right to appeal and explained to her what information she could provide them for the appeals process.

The Administrative Appeal

While Plaintiff prepared records for the administrative appeal of the denial of her LTD benefit claim, on March 30, 2017 Aetna informed her that it was terminating her claim for STD benefits. The letter stated, “you may have impairment however clinical on file does not support impairment from performing sedentary physical demand level work.”

In support of Plaintiff’s administrative appeal, Plaintiff’s physician and PA both wrote letters to Aetna explaining the multiple symptoms Plaintiff experienced and that the symptoms were consistent with a diagnosis of CFS which made it impossible for her to work. Both health care providers noted there were days Plaintiff was unable even to get out of bed. Although she tried to exercise daily, these were not exertional exercises but were low-intensity modified Yoga and Pilates-based stretches to benefit her back problems.

In a letter to Aetna, Plaintiff recounted her medical history including all her many doctor visits and lab results which supported the physician’s diagnosis of immunodeficiency antibody deficiency, and adrenal fatigue. She also submitted medical articles supporting her abnormal test results as indicative of immunodeficiency which the Court later found supported a diagnosis of CFS.

An Aetna Vocational Consultant determined Plaintiff’s job was “a sedentary physical occupation” and made some notes concerning Plaintiff’s specific job description. Aetna also assigned a review of medical records to an outside vendor who hired endocrinologist Dr. Cooper to conduct the review. Cooper concluded that “There is no credible evidence to support ongoing impairment.”

Aetna gave Plaintiff’s doctor and PA a chance to respond to Dr. Cooper’s recommendation. They both responded separately and concurred that endocrinologist Dr. Cooper, “completely disregarded Plaintiff’s diagnosis.” Dr. Cooper did not change his mind and still opined that Plaintiff could perform her job duties.

Aetna then sent the records to a second reviewer who concluded that even though she consistently complained about fatigue, “Plaintiff’s subjective complaints were inconsistent with her level of activity and unsupported ‘by any examination and/or diagnostic findings.’”

On December 17, 2017, Aetna sent Plaintiff a letter denying her claim for LTD benefits. The denial was based on “the lack of sufficient evidence of ongoing impairment and the finding of Plaintiff’s ‘capacity to perform [her] own occupation, as a Senior Business Analyst, which is a sedentary physical demand level.”

Having exhausted her administrative remedies, Plaintiff filed this ERISA lawsuit in the United States District Court for the Central District of California complaining that the disability insurance denial was erroneous. The Court conducted de novo review and concluded “that Plaintiff adequately proved both her disability and functional impairment under the ‘own occupation’ of the Group Policy’s definition of ‘Total Disability.’’

Chronic Fatigue Syndrome is a Disabling Condition

The Court found that the file was “replete with evidence that Plaintiff suffers from a disability.” The Court relied partially on evidence from the Centers for Disease Control and Prevention (CDC) verifying that a diagnosis of CFS is based on symptoms. The U.S. Court of Appeals for the Ninth Circuit has held that “there are no objective tests for Chronic Fatigue Syndrome.”

The Court itemized Plaintiff’s symptoms and concluded, “Plaintiff has demonstrated by a preponderance of the evidence that she suffers from clinically evaluated, unexplained, and persistent chronic fatigue of new onset.” The Court also found that “at the very least,” the Administrative Record supported a finding that Plaintiff “suffers from Chronic Fatigue Syndrome.” The Court found Plaintiff’s attending physicians “more reliable witnesses” than Aetna’s consultants who reviewed Plaintiff’s file.

Having found that Plaintiff had a disabling condition, the Court continued its analysis to determine whether that condition interfered with Plaintiff’s ability to perform the material and substantial duties of her own occupation.

Plaintiff Proved That Her Medical Condition Made it Impossible for her to Perform the Duties of Her Own Occupation and Aetna Applied the Incorrect Definition of Disability

Aetna denied Plaintiff’s claim on the grounds that it believed Plaintiff could work in a sedentary position. The Court noted that Aetna used the incorrect definition of disability according to the terms of the Group Policy.

The Court noted that during the first 24 months, “The relevant standard, however, is not whether a claimant is unable to perform a sedentary occupation; it is whether a claimant can ‘perform with reasonable continuity the substantial and material acts necessary to pursue [the claimant’s] own occupation.’”

The Court itemized Plaintiff’s job duties of a Senior Business Analyst provided to Aetna by First American. The Court also reviewed Aetna’s notes on Plaintiff’s case which itemized the detailed and intricate job duties required. The Court found that “It is obvious her fatigue would impair her ability to carry out the wide array of analytical, strategic, and managerial tasks that were expected of her in the regular course of her own occupation as a Senior Business Analyst.”

The Court concluded that “Plaintiff proved (1) that she suffers from a disease or disability, and (2) that her disease or disability functionally impairs her from carrying out the substantial and material acts necessary to pursue her own occupation. Defendant’s determination to the contrary was erroneous.”

Court’s Final Order

The Court held that “Plaintiff shall be awarded past-due benefits, prejudgment interest, attorneys’ fees, and costs through the ‘own occupation’ period under the Group Policy.” The Court remanded to the Plan Administrator for further deliberation, “consistent with this order and the requirements of ERISA to determine Plaintiff’s eligibility for further LTD benefits under the “any occupation” standard.”

This case was not handled by our law firm, but we believe it can be instructive to those who have been denied LTD benefits and need assistance with their administrative appeals or with filing an ERISA lawsuit. For questions about this or any aspect of either your STD or LTD benefits, contact one of our disability attorneys at Dell & Schaefer for a free consultation.

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