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Is a Claimant’s Complaints of Pain Enough to Qualify for Short or Long Term Disability Insurance Benefits?



Attorney Gregory DellAuthor: Attorney Gregory Dell

The answer to this question applies to the vast majority of long term disability insurance claims that we handle on a daily basis. Pain is subjective. This means that there is no medical device or verifiable method for confirming pain. A claimant’s ability to collect disability benefits based upon pain will depend upon the level of documentation and treatment received from treating physicians. In a recent case in Pennsylvania against the Cigna Insurance company (Horn v. LINA 7/22/15) the court stated as follows:

It is well established that “pain in itself may be disabling.” Brown v. Cont’l Cas. Co., 348 F. Supp. 2d 358, 367 (E.D. Pa. 2004) (citing Chrupcala v. Heckler, 829 F.2d 1269, 1276 n.10 (3d Cir. 1987) (“Pain itself may constitute a disabling impairment.”); Smith v. Califano, 637 F.2d 968, 971 (3d Cir. 1981)). “Nonetheless, where claims as to the existence or degree of subjective pain are unsubstantiated, the plan administrator has the discretion to disregard them.” Eppley v. Provident Life & Acc. Ins. Co., 789 F. Supp. 2d 546, 572 (E.D. Pa. 2011). In Black & Decker Disability Plan v. Nord, 538 U.S. 822 (2003), the Supreme Court held that ERISA does not require plan administrators to “accord special deference to the opinions of treating physicians. Nor does the Act impose a heightened burden of explanation on administrators when they reject a treating physician’s opinion.” Id. at 831. However, Nord “does [not] insulate plan decision makers whenever they reject a treating physician’s opinion in favor of a consultant’s opinion.” Matson v. AXA Equitable Life Ins. Co., No. 10-cv-5361, 2011 WL 4345848, at *7 (E.D. Pa. Sept. 15, 2011) (alteration in original) (quoting Kaufman v. Metro. Life Ins. Co., 658 F. Supp. 2d 643, 649 (E.D. Pa. 2009)) (internal quotation marks omitted). The court “may still evaluate the weight of each doctor’s opinion based on the extent of his or her treatment history with the patient…” Brown v. Cont’l Cas. Co., 348 F. Supp. 2d 358, 368 (E.D. Pa. 2004). Moreover, where a disease is “subjective and variable,” direct contact with a patient over an extended period of time seems “especially important” since it can allow “more thorough examination of the patient’s credibility and true range of abilities.” See id.

It is never enough for a claimant to just state that they cannot work due to pain. The pain must be well documented by the claimant’s treating physician(s). Please read the attached opinion from the Eastern District Court of Pennsylvania to learn more about the type of evidence that a court looks for in order to support a disability claim based upon pain complaints. Contact any of our long term disability insurance lawyers to discuss how we could assist you with you claim for benefits.

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