In a recent case out of Massachusetts, a federal district court addressed several often contested issues in the area of ERISA including how insurance companies are supposed to evaluate disability claims that are based on conditions like fibromyalgia which are based primarily on subjective complaints and who has the burden of proof when a policy limitation comes into play.
Terminated after receiving nine years of benefits
There were two policies in play – a group ERISA governed policy and an individual policy issued by Provident Life. This claimant, Judith Kamerer was receiving disability benefits due to debilitating symptoms caused by fibromyalgia and depression.
After paying benefits to Ms. Kamerer for 9 years and despite the absence of improvement in her conditions Unum terminated Ms. Kamerer’s benefits and deemed her capable of returning to work in her prior occupation.
Unum’s decision was based in part on an independent medical evaluation by a doctor who concluded that fibromyalgia diagnosis was supported but still deemed Ms. Kamerer capable of performing sedentary work in the “absence of objective findings of abnormalities on examination.” The same doctor also concluded that there was support for pain associated with psychological factors, depression and hypothyroidism.
Naturally, an appeal followed and after Ms. Kamerer’s appeal was denied she took her chances with a federal judge when she filed a lawsuit in federal district court.
On review, the court acknowledged that there was no dispute as to the fibromyalgia diagnosis and further observed that under first circuit precedent it is unreasonable to require objective evidence to support a diagnosis such as fibromyalgia that cannot be objectively verified. However, the court also recognized that the claimant is still required to provide objective proof of the physical limitations imposed by the symptoms from her illness.
Nonetheless, even if a claimant is unable to provide objective evidence that her symptoms preclude her from fulfilling the physical requirements of her occupation she can still satisfy the burden of proof if the totality of the evidence demonstrates that she is unable to fulfill them.
The court looked at a number of things including the subjective complaints which, according to the court, should be considered since although subjective reports of pain are difficult to prove they should still be afforded some weight. The court also noted the claimant’s history of treatment finding it significant and improbable that a claimant would have undergone the pain-treatment procedures that she did including heavy doses of strong drugs merely to strengthen her credibility of her pain to increase her chances of getting disability benefits. It was also considered improbable that the various medical providers would prescribe drugs and other treatment for her if they thought she was faking her symptoms.
The court found Ms. Kamerer credible. The available objective evidence and overwhelming subjective evidence credited by medical professionals was sufficient for the court to find that Ms. Kamerer had satisfied her burden of demonstrating that she is disabled.
The Court shifts the burden to Unum
After finding for Ms. Kamerer the court took it a step further and went on to address an issue on which courts have taken contrary positions and one which many courts often avoid discussing – the burden of proof when a limitation applies.
When reviewing Ms. Kamerer’s claim, Unum had determined that several diagnoses were supported including mental health conditions which would invoke the 24-month mental nervous limitation. The court concluded that once Ms. Kamerer demonstrated her disability that Unum should be the one to demonstrate why Ms. Kamerer is not entitled to those benefits. It appeared the court’s decision was mainly influenced by the length of time that benefits had been paid uninterrupted. It was not until after paying benefits for nearly 10 years that Unum alleged that Ms. Kamerer’s disability was due to psychological conditions.
The court found that Unum failed to meet its burden of proving by a preponderance of the evidence that Ms. Kamerer’s disability was “due to” or “caused by” mental illness.
This case is considered a big win; however, it is important to remember that while a carrier cannot require objective evidence of conditions that are primarily subjective in nature it is still the claimant’s responsibility to provide proof of the physical limitations caused by the symptoms from that illness. Such evidence is often difficult to provide. Also, the court’s decision in this case relied heavily on the particular facts of Ms. Kamerer’s claim. The period of time she was on claim before Unum attempted to invoke the limitation was key. However, the court did not discuss in detail the reasons it believed Unum did not meet its burden. It seems Unum failed to perform or even request an evaluation by a doctor of the correct medical specialty that could corroborate the assertion that Ms. Kamerer’s disability had a psychological component.
This case was not handled by Attorney’s Dell & Schaefer but we have handled thousands of cases against Unum. If you have a similar claim against Unum or any major disability company feel free to contact any of our attorneys for a free consultation.