The Indiana federal district court case of Kennedy v. Lilly Extended Benefit Plan is a refreshing example of how perseverance in asserting a claim for long term disability benefits after they have been terminated can pay off. The plaintiff suffered from the pain and stress of fibromyalgia as well as other medical problems which turned out not to be relevant to the court’s order that Anthem reinstate her benefits. The court ruled that remanding the case would be a “useless exercise because the Court has reviewed the evidence in the record and determined that it does not offer any affirmative support for terminating Kennedy’s benefits.”
After working for 25 years for Eli Lilly and Company, the plaintiff was diagnosed with fibromyalgia. Her initial claim for long term disability benefits was granted based on the opinion of her treating physician, a rheumatologist, that she was disabled from performing the tasks of her own occupation. Two years later, the administrator of the plan, Anthem Life and Disability, terminated her benefits based on the medical record review of another rheumatologist, Dr. Dikranian. According to Dikranian, there was no documentation in the medical records of the fibromyalgia diagnosis and no “signs and symptoms to support this diagnosis.” Kennedy appealed the termination of her benefits.
Thus began a long, convoluted fight with Anthem who subjected Kennedy to a number of Independent Medical Exams (IME). The first one was conducted by a rheumatologist, Dr. Neucks, who later became Kennedy’s treating physician. Neucks concurred with the opinion of the treating physician. Anthem was, of course, not satisfied with this opinion so sent her to yet another rheumatologist for a second IME by Dr. Schriber. Finally, Anthem got what it wanted. Dr. Schriber issued a report saying the medical record did not support the disability finding. He also erroneously stated that the American College of Rheumatology “does not consider fibromyalgia to be disabling on a long-term basis.”
Anthem also asked a board certified rheumatologist, Dr. Payne, to conduct a peer review of the file. He concluded that all the laboratory results were normal. Since there was no “clinical evidence” to support the severity of her condition, he stated that she was not disabled under the terms of the plan. Anthem refused to reinstate her long term disability benfeits and she filed a lawsuit under ERISA.
Lilly’s Errors According to the Court
The federal court found Anthem had committed several errors in terminating Kennedy’s benefits.
- The court relied on Seventh Circuit precedent which has rejected the theory that claimants must provide objective evidence of their disability when no objective evidence exists for the condition stating that “pain often and in the case of fibromyalgia cannot be detected by laboratory tests.”
- Even if there had been objective evidence, Anthem never informed Kennedy that she need to provide that type of evidence in support of her claim. This failure deprived her of “the opportunity to correct that omission on appeal, thus denying her a full and fair opportunity for review.”
In ordering Anthem to reinstate long term disability benefits, the court concluded that since Kennedy was never informed of the need to provide objective evidence, it would be impossible for her to back in time to document what her degree of functional capability was in 2010. The court determined the “appropriate remedy in this case is the reinstatement of benefits.”
This ERISA case was not handled by our disability attorneys, but it is a victory for fibromyalgia claimants. It may help others with that disease in their pursuit of long term disability benefits.