LINA and CIGNA need to listen to the Federal Courts and stop denying disability insurance claims for people disabled by fibromyalgia
An affirming opinion from the Fourth Circuit United States Court of Appeals shows how Administrators of ERISA long term disability benefits can’t abuse their power of discretion in North Carolina. This case against LINA also known as CIGNA, is a great victory for claimants suffering from fibromyalgia. In the appeal of Rebecca DuPerry v. Life Insurance Company of North America, Appellee Rebecca DuPerry prevailed in her quest to receive long-term disability benefits from her group long term disability insurance provider, Life Insurance Company of North America (LINA).
Rebecca DuPerry was employed as a payroll and benefits clerk for Railroad Friction Products Corporation until April 2006, when she succumbed to her disability, documenting that she suffered from rheumatoid arthritis, osteoarthritis, and fibromyalgia. A phrase in DuPerry’s Attending Physician’s Statement of Disability stated that DuPerry “would ‘never’ be able to return to work” as her limitations for motion were in the lowest category of physical fitness, “sedentary,” which means is defined as being restricted to “a maximum lifting weight of 10 lbs and occasional walking.” The case manager handling DuPerry’s claim considered this document as well as a blood test report and a physical therapist’s report during her evaluation. The blood test showed normal results and the physical therapist reported that Ms. DuPerry had made some small strength and endurance gains in the 9 months she had undergone therapy and was very cooperative.
The case manager asked for clarification of the “sedentary” designation from DuPerry’s physician, who responded that DuPerry’s fibromyalgia, fatigue and pain medication side effects prevented her from being able to work even though her rheumatoid arthritis was currently under control. Even with this information LINA determined that DuPerry had not provided sufficient proof of a continuing disability and denied her long-term disability benefits in a letter dated November 10, 2006.
DuPerry appealed this decision by letter on May 7, 2007 with some 400 pages of documentation to verify her condition. She provided LINA with:
- Letters from her doctors confirming the worsening of her condition from May 2005 (when she was already being pressured by her doctor to cease working) through 2006
- Letters from her physician explaining how that even though DuPerry’s arthritis was somewhat controlled with medication and her fibromyalgia and fatigue symptoms were manageable with medication, she was unable to function well enough to work
- Exam reports that noted the amount of pain medication DuPerry had to take to get a small amount of pain relief
- Physician notes recording DuPerry’s osteoarthritis issues and the medication required to help her cope with that issue
- Letters from her former employer, filled with accolades of DuPerry’s work and positive attitude
- Letters from her former employer that described the deterioration of DuPerry’s health during her employment
Undeterred, LINA denied DuPerry her long-term disability benefits, stating that DuPerry’s condition did not “preclude work at the sedentary demand level.” As follow-up to the denial by LINA of her disability benefits, DuPerry filed a second appeal and included additional medical records that included videos of DuPerry at home. The case manager in this second appeal concluded that DuPerry’s physical condition and the pain DuPerry experienced were primarily a result of her fibromyalgia and again said the documentation did not provide adequate evidence to support DuPerry being classified as a candidate for LINA’s long term disability benefits. Again DuPerry was denied her claim for disability benefits.
On July 18, 2008, DuPerry and her disability lawyer filed a lawsuit in North Carolina District Court alleging she was wrongfully denied her disability benefits by LINA. On August 10, 2009, the District Court ordered LINA to pay DuPerry her disability benefits from the expiration of her elimination period through the date of the Order. In addition, the Court awarded DuPerry’s disability attorney’s their attorneys fees as well as prejudgment interest.
Unfortunately, this was not the end of DuPerry’s legal battles as LINA appealed the North Carolina District Court’s ruling and was granted a hearing. LINA’s appeal further delayed the period of time that DuPerry needed to wait until she would be paid her disability benefits.
Court of Appeals holdings concerning DuPerry’s disability benefits award
After reviewing the voluminous filings and documentation in this case, the Court of Appeals wrote a lengthy opinion in which the observation was made that this type of ERISA case is difficult to rule upon in that pain is a subjective determination. And, while a beneficiary of a disability claim based on a complaint of pain should not be granted without proper evidence to support the claim, the plan administrators should not easily dismiss pain as a debilitating symptom “out of hand.”
After careful deliberation and the evaluation of all the issues in this case, the Court of Appeals held that:
- administrator abused its discretion in denying participant’s application;
- district court was within its discretion in awarding benefits, rather than remanding to administrator; and
- district court did not abuse its discretion in awarding attorney fees.