Attorney Rachel Alters filed an appeal after Lincoln denied long-term disability benefits to a Project Manger suffering from chronic paroxysmal hemicrania/hemicranial cluster headaches, cervicalgia, and osteoarthritis of the temporomandibular joint bilaterally, which prevented her from being able to perform with reasonable continuity each of the main duties of her regular occupation. It was evident from review of the denial letters and claim file that Lincoln had failed to understand the significance of the claimant’s medical condition and its impact on her ability to perform the main duties of her occupation.
Two appeals were filed on the claimant’s behalf, the first by the claimant and the second by Dell & Schaefer. After conducting a second internal review Lincoln determined it decision to deny LTD benefits was wrong, paid all of her past benefit since December of 2012 and put the her back on claim.
Paroxysmal Hemicrania/Hemicranial Cluster Headaches
According to the National Institute of Neurological Disorders and Stroke, paroxmal hemicrania is “a rare form of headache that usually begins in adulthood. Patients experience severe throbbing, claw-like or boring pain usually on one side of the face; in, around or behind the eye; and occasionally reaching to the back of the neck. This pain may be accompanied by red and tearing eyes, a drooping or swollen eyelid on the affected side of the face, and nasal congestion. Patients may also feel dull pain, soreness or tenderness between attacks. Attacks of paroxysmal hemicrania typically occur from 5 to 40 times per day and last 2 to 30 minutes. This disorder has two forms: chronic, in which patients experience attacks on a daily basis for a year or more, and episodic, in which the headaches may remit for months or years. Certain movements of the head or neck or external pressure to the neck may trigger these headaches in some patients. The disorder is more common in women than in men.”
The Mayo Clinic defines cluster headaches as follows: “Cluster headaches occur in cyclical patterns or clusters, which gives the condition its name. Cluster headache is one of the most painful types of headache. Cluster headache commonly awakens you in the middle of the night with intense pain in or around one eye on one side of your head. Bouts of frequent attacks, known as cluster periods, may last from weeks to months, usually followed by remission periods when the headache attacks stop completely. During remission, no headaches occur for months and sometimes even years. Fortunately, cluster headache is rare and not life-threatening. Treatments can help make cluster headache attacks shorter and less severe. In addition, medications can help reduce the number of cluster headaches.”
The claimant began suffering from the above-described severe headaches during the third trimester of her pregnancy. After she gave birth to her son, the headache pain significantly worsened and became completely debilitating. The medical records that were provided to Lincoln documented attempts to diagnose and treat her condition. She had been evaluated by numerous physicians and specialists: neurologists, otolaryngologists, an oral and maxillofacial surgeon, orthopedic surgeon, chiropractor, acupuncturist, ophthalmologist, pain specialist, as well as her primary care physician. She has undergone multiple MRIs of her brain, as well as her TMJ and cervical spine. She has endured EMGs, nerve conduction studies, ECGs, and has been tried on numerous medications and even botox injections. Though she had been able to obtain some relief, the severe, debilitating headaches defined as paroxysmal hemicrania or hemicranial cluster headache continued.
Lincoln Conducted a Substandard Review of the Claim
In review of the first appeal, Lincoln sent her file to an internal medicine physician for a paper review of the medical records. The physician did not meet, examine, or speak with the claimant, nor did she attempt to speak with any of her multiple treating physicians for further insight into her medical condition.
Lincoln’s physician rendered the following opinion:
“The claimant is unable to perform safety sensitive duties such as no working at heights, no operating heavy machinery and no driving commercial vehicles. The evidence within the file does not support findings of warranted restrictions and/or limitations that would preclude the claimant’s ability to perform in her own sedentary occupation from 6/15/2012 forward… The records support that the claimant is able to fulfill activities of daily living (ADLs) and care for her infant and her family. The records do not support total inability to work. The claimant would be capable of performing in her own sedentary occupation.”
Based on the above opinion, Lincoln made the decision to uphold the denial her claim for long term disability benefits. However, Lincoln neglected to address why it failed to give weight to the contrary opinions of her treating physicians that she was not capable of working, nor did they address why its doctor did not give any weight to the opinions and findings of the treating physicians or what evidence her proposed restrictions and limitations were based on. As such, it was apparent that Lincoln accepted the opinion that suited their goal of denying the claim for LTD benefits, against the weight of the actual medical evidence from the treating providers which lends to a contrary finding that the claimant is disabled under the Long Term Disability Policy. Attorney Alters submitted a second appeal addressing each issue presented in Lincoln’s denial letter and submitted supporting opinions from several of the claimant’s treating physicians all attesting to her inability to work. After conducting another review, Lincoln overturned its original decision to deny her benefits, paid her past benefits owed to her and put her on claim.
Dell & Schaefer will continue to manage her claim to help ensure she remains on claim until she is well enough to return to work.