A Utah Federal Judge reversed a Hartford long term disability insurance benefit denial on the basis that it was “unreasonable and, thus, arbitrary and capricious”. The judge’s opinion in this case is a great victory for disability insurance claimants disabled by Fibromyalgia or by Chronic Fatigue Syndrome. Additionally, the Judge that decided this case should be commended for seeing through Hartford’s bullshit review of the file and taking the time to actually understand the Plaintiff’s inability to work.
The plaintiff in this case was a 60 year old male, previously employed by Van Gilder Insurance Company as a health insurance salesperson. The Plaintiff initially filed and was approved by Hartford for Short term and long term disability benefits in Jun 2006. Approximately 3.5 year later, Hartford denied the claimant’s benefits in February 2010, which was a few months after the definition of disability changed from “own occupation” to “any gainful occupation”. Hartford relied on the following information in order to deny the long term disability claim:
- Six non consecutive days of video surveillance (one day had the claimant playing golf for 4.5 hours)
- Three different file medical reviews by doctors hired by Hartford
- Hartford sent a representative to the Claimant’s house to interview him
- Hartford had their hired doctors call and speak with three of the claimant’s treating physicians; and
- Hartford sent the video surveillance to the treating doctors asking if they though the claimant’s medical condition was consistent with the video surveillance. (One of the claimant’s treating doctors responded that he thought the claimant could work 40 hours a week based upon his activities in the videos.)
The claimant and his Utah disability attorney filed an ERISA lawsuit against Hartford. After several month of litigation the Plaintiff won! The Utah Court’s primary basis for reversing Hartford’s denial was that Hartford should have exercised their right to have the Claimant physically examined by a doctor of their choice. The judge stated,
The Court recognizes that physical examinations are not requisite in all cases for an insurer’s decision to be reasonable. But the Court also considers Defendant’s decision to conduct file reviews rather than a physical examination as another factor in the overall assessment of whether Defendant acted reasonably. Calvert, 409 F.3d at 295. In Calvert, the Sixth Circuit Court of Appeals stated, “while we find that [Defendant’s] reliance on a file review does not, standing alone, require the conclusion that [Defendant] acted improperly, we find that the failure to conduct a physical examination… may, in some cases raise questions about the thoroughness and accuracy of the benefits determination.” Id. The Court finds this reasoning applicable to the current case.
The Utah court discussed that Fibromyalgia and Chronic Fatigue are subjective medical conditions and stated,
Fibromyalgia and Chronic Fatigue Syndrome, are problematic for insurers and courts evaluating disability claims because proving the diseases is difficult given the subjective nature of the symptoms. See Welch v. UNUM at 1086, 87 (citing Walker v. Am. Home Shield Long Term Disability Plan, 180 F.3d 1065, 1067 (9th Cir. 1999) (“Because proving the disease is difficult… fibromyalgia presents a conundrum for insurers and courts evaluating disability claims”). Compare Jordan v. Northrop Grumman Corp. Welfare Benefit Plan, 370 F.3d 869, 872 (9th Cir. 2004) (“[F]ibromyalagia’s cause or causes are unkown, there is no cure, and, of greatest importance to disability law, its symptoms are entirely subjective.”); Hawkins v. First Union Corp. Long-Term Disability Plan, 326 F.3d 914, 919 (7th Cir. 2003) (noting that fibromyalgia “itself can be diagnosed more or less objectively by the 18-point test …but the amount of pain and fatigue that a particular case of it produces cannot be”); with Boardman v. Prudential Ins. Co. Of Am., 337 F.3d 9, 16 n. 15 (1st Cir. 2003) (“While the diagnoses of chronic fatigue syndrome and fibromyalgia may not lend themselves to objective clinical findings, the physical limitations imposed by the symptoms of such illnesses do lend themselves to objective analysis”).
Fibromyalgia disability claims are often challenged by disability insurance companies. In the past few years the condition has become more recognized and Court’s are coming down on disability insurance companies that do not give fair weight to the diagnosis. Our disability attorneys have represented hundreds of claimants disabled by fibromyalgia and understand the disabling effects it has on a person’s ability to work 40 hours a week.
The court discussed Hartford’s wrongful reliance on on 6 days of video surveillance. The court stated that Hartford had paid the claimant for more than three years and the video surveillance did not prove that either the claimant’s medical condition had improved or he was capable of working 40 hours a week. The video surveillance did not reveal any new information about the claimant and was not substantial evidence supporting the insurance company’s decision to terminate benefits. The court specifically stated that 4.5 hours of golf out of 6 days of surveillance “is not substantial information regarding Plaintiff’s ability to maintain a full time job.” The court also states that people receiving disability insurance should not be dissuaded from leaving their homes for fear of losing their benefits.
You can read the Court’s 19 page full opinion by clicking here (PDF).