Objective medical evidence of fibromyalgia may not always be required to prove total disability

Citation: Klimas v. Conn. Gen. Life Ins. Co., NO. 2:04-CV-05408-LDD 2005 U.S. Dist. LEXIS 18555.

Jennifer Klimas, an account executive for Sprint PCS, procured a group long-term disability policy through her employer that was funded and administered by Connecticut General Life Insurance Company (hereinafter “Connecticut General”).

In July 2002, Ms. Klimas underwent surgery to remove a fibroid on her uterus and later filed for long-term disability benefits due to experiencing ongoing abdominal pain, anxiety, fatigue and chronic pain post surgery. Approximately one year after the surgery, Ms. Klimas was diagnosed with fibromyalgia.

In April 2003, Connecticut General denied Ms. Klimas’s claim for long-term disability benefits. Ms. Klimas appealed Connecticut General’s denial by submitting an award granting Social Security disability benefits and updated medical records from her treating physicians. The newly submitted medical records reflected the following:

1. Ms. Klimas complained of abdominal pain, constipation, nausea, fatigue and tiredness;
2. Ms. Klimas suffers from chronic whole body pain consistent with fibromyalgia;
3. Ms. Klimas suffers from chronic pain syndrome with uncertain etiology;
4. Ms. Klimas suffers from chronic pain, fatigue, fibromyalgia and psychological and emotional problems; and
5. Ms. Klimas is physically and emotionally disabled from working.

However, despite a plethora of medical evidence substantiating Ms. Klimas’s disability, Connecticut General continued to deny her claim for disability benefits. Connecticut General cited an absence of objective medical documentations substantiating that Ms. Klimas suffered from a condition that would preclude her from working.

Ms. Klimas sued Connecticut General, seeking benefits under the terms of her group disability policy. The court found that Ms. Klimas was entitled to past due, present and future long-term disability benefits according to her disability plan. Specifically, the court found that medical records from treating physicians provided ample evidence that Ms. Klimas was totally disabled within the meaning of the plan due to fibromyalgia and chronic pain syndrome symptoms, such as, fatigue, pain, nausea, and constipation. Additionally, the court found the denial failed to reference, let alone consider, the findings of the Social Security Administration, which concluded that Ms. Klimas was disabled. Furthermore, the court found that Connecticut General improperly injected into the analysis, the requirement that she produce objective medical evidence to validate her fibromyalgia and chronic pain syndrome, since the plan did not impose a “per se ruling requiring objective clinical evidence of the etiology of a claimant’s disabling condition prior to satisfying the definition of totally disabled.”

It is important to know the terms of your policy in order to be able to understand your rights and stand up to the insurance company if necessary.