When Ruth Jobe lost her ERISA disability lawsuit in District Court, she could have decided that there was no hope for recovering the disability benefits she believed Dearborn National/Dearborn Group had wrongfully denied her. When she listened to the wisdom of her disability insurance attorney and appealed the decision of Judge Laughrey of the Western District of Missouri’s Central Division, it proved to be a wise decision. The District Court judge had chosen the wrong standard of review. When the Court of Appeals applied the correct standard, it made all the difference for her claim.
As we usually do in these cases, we will take some time to consider the background behind Jobe’s disability claim. These facts not only share insights into the reasons a person can become disabled, but also shed light on the ways in which long-term disability plans seek to divest themselves of the obligation to pay long-term disability benefits.
As a medical transcriptionist with Lake Regional Health System, Jobe participated in a disability benefits insurance plan issued by Dearborn National/Dearborn Group. This long term disability plan was governed by the Employee Retirement Income Security Act (ERISA) passed by Congress in 1974.
Disability attorney studies the terms of the different disability plan documents.
One of the basic requirements under ERISA is that the terms and conditions of a long-term disability plan must be written. In this case, the Disability Plan terms appeared in more than one document. The first document was called the “Group Insurance Policy” or “Plan.” It defined the key terms and explained the benefits offered by the Plan. This document contained a series of clauses, one of which informed the policy holder that if there was a difference between the Certificate issued to the policy holder and the “Group Insurance Policy” document, the “Group Insurance Policy” document would govern.
The certificate of coverage was included in another document, “Voluntary Long-Term Disability Insurance: Employee Benefit Booklet.” This booklet also described the coverage provided by the policy. An “ERISA Information Statement” was attached to the booklet that once again stated that if there was a conflict between the “Employee Benefit Booklet” and the “Plan”, the Plan would control. Jobe’s disability attorney caught this small detail.
Disability attorney’s client suffers from multiple disabling conditions.
Jobe’s health problems began when she was diagnosed on January 22, 2001 with polycythemia and polycythemia vera, a blood condition that involves the production of excess red blood cells. Typical symptoms include blood clots, dizziness and headaches. Jobe also began experiencing issues with her vision in 2003. The diagnosis was amaurosis fugax and ischemic optic neuropathy. Then on April 15, 2004, she was diagnosed with fibromyalgia as well. She then underwent a hysterectomy on June 23, 2004.
Jobe applied for disability benefits on July 2, 2004. The physician statement she included with her application noted that Jobe had a wide array of health issues including: 1) Fibromyalgia, 2) CVA/TIA, 3) Worsening polycythemia rubra vera resulting in prolonged severe hemorrhage & hysterectomy. The statement also presented a list of objective findings: limited range of motion in joints, spine, hands, fingers, multiple neurologic deficits – “treatment limited due to other medical conditions as listed.” Jobe’s doctor also reported that Jobe’s functional capacity as defined by the American Heart Association was Class 4 – complete limitation. He described her physical impairments as defined by the Federal Dictionary of Occupational Titles as Class 5 – Severe Limitation of functional capacity. He included minimum (sedentary) activity. He considered her mental impairments less severe in Class 3 – only able to engage in limited stress situations and engage in limited interpersonal relations with moderate limitations.
A month later the same doctor sent a more detailed description of Jobe’s medical conditions. The doctor made it clear that she was totally disabled. He considered her condition permanent and terminal.
Dearborn let Jobe know on August 13, 2004, that the disability plan had received her claim and had asked Disability RMS (DRMS) to handle the processing of her claim. DRMS is a third party administrator. They faxed the claim to DRMS on the same day. It wasn’t until Jobe contacted Fort Dearborn on August 30, 2004, informing them that DRMS had told her that they had no record of her claim, that Dearborn knew that the claim had been lost.
When DRMS finally did get the claim, its response back to was “Wow! This is a crazy one!” DRMS collected records from no less than eight physicians who had treated Jobe. Then on September 20, 2004, DRMS sent Jobe’s file for medical review. This doctor stated that the medical data she had received failed to support the TIA/CVA and polycythemia vera diagnosis. She concluded that if Jobe’s employer accommodated certain restrictions on work, she should be able to work full-time.
This doctor concluded that the reasonable restrictions and limitations with fibromyalgia are:
Changes in position as needed, with no prolonged sitting, standing, or walking at any one given time. No lifting more than 20 lbs. occasionally. No prolonged static posturing. No prolonged activities with the arms above shoulder level.
She then sent a series of form letters to Jobe’s treating physicians.
One doctor checked the yes box beside the question asking whether Jobe would be able to work if certain restrictions and limitations were accommodated in the workplace. Another doctor wrote a detailed response rebutting the DRMS doctor’s conclusions and reaffirming the validity of Jobe’s diagnosis in detail.
DRMS sent Jobe’s file to another doctor for review. This physician also claimed in his October 26, 2004 report that the diagnoses were not supported by the medical documentation. This physician drew no conclusions as to whether Jobe needed accommodation in the workplace.
Based on the conclusions presented by the two doctors it had hired to review Jobe’s file, Dearborn denied Jobe’s claim on November 15, 2004. A DRMS employee emailed Jobe’s claim handler the same day the letter went out the following message, “I loved your 9 page denial letter.”
Jobe appealed the claim denial in a 16-page letter. A different claims handler took over her file and sent her file to a third doctor for review. This physician also claimed that her doctor’s records failed to include any records upon which to conclude that Jobe was “disabled due to the multiple conditions claimed.” This doctor’s conclusion was that there was no “evidence of limitations from a sedentary to light position consistent with a medical transcriptionist position.” At this point, Jobe’s doctor wasn’t much help. He responded to the report by stating that he didn’t agree, without adding any further information.
DRMS also had a vocational consultant look at Jobe’s file. The consultant concluded that a medical transcriptionist job was already a sedentary position. With ergonomically correct work stations and the allowances most employers already allowed for changing positions, there was no reason that Jobe could not continue working in her opinion.
This news was greeted warmly by the claims handler. This second handler prepared a denial letter number two on February 28, 2005.
It took some time for Jobe to request her second appeal. When she did so on August 25, 2005, she submitted additional medical information. She also included information from an unfavorable Social Security Administration decision issued on August 16, 2004. Her file was sent for review again, and came back with the same conclusion, the medical information failed to support her disability claims. Proving her disability had become even more difficult by this time, because her physician reported that her primary issue was now chronic fatigue immune dysfunction syndrome.
The third and final denial letter went out on December 19, 2005. Dearborn National/Dearborn Group made it clear that this was the “final review”. Jobe’s administrative remedies were exhausted. When Social Security found her disabled in September 2006, Jobe made one last effort to appeal Dearborn National/Dearborn Group’s denial. An October 6, 2006 letter made it clear that Dearborn had no intention of changing its position. Jobe would have to take her ERISA claim before the Courts by filing a lawsuit in Federal Court.
This would prove a long battle for Jobe and her disability attorney. They would face Dearborn National/Dearborn Group twice – first in U.S. District Court, then in the U.S. Court of Appeals. In another article we will discuss the legal victory obtained by Jobe’s disability attorney which resulted in an additional review of the claim denial by the US District Court. Jobe still has a long way to go in her litigation of this disability claim.