As an employee of Prudential Insurance Company of America (Prudential), Duane Morgan might have expected more of his employer when he had to take advantage of the long-term disability plan offered as part of his employment package. He had been a senior life representative when symptoms of chest pain, palpitations and dizziness, sweating and shaking, numbness in his arms, high blood pressure, difficulty sleeping, and diarrhea forced him to stop working in September 2005.
Prudential approved him for disability benefits based upon its finding that he was suffering from a major depressive disorder, anxiety and hypertension. He began receiving benefits on October 15, 2005. On March 28, 2006, Prudential converted his short-term disability benefits into long-term disability benefits. Then at the end of two years, on March 28, 2008, Prudential notified Morgan that his benefits were being terminated because his disability was “mental health diagnosis of depression and anxiety.” The company cited its mental illness limitation which capped benefits at 24 months.
Morgan appealed the termination of his benefits, claiming that he was disabled from fibromyalgia, not depression. He included a letter from his rheumatologist which confirmed the diagnosis of fibromyalgia. Prudential sent his file for review, and based upon that review Prudential denied Morgan’s appeal, continuing to hold that Morgan’s disability was the result of depression, not fibromyalgia.
Claimant Files an ERISA Disability Lawsuit against Prudential
The first concern for the court was to determine which standard of review would apply. Prudential had discretion to interpret the plan and to decide whether benefits were payable. This meant that the court would use the arbitrary and capricious standard of review.
Morgan’s disability attorney pointed to the fact that there was a conflict of interest, despite the fact that Prudential funded its benefit plans through a trust and made fixed contributions to the trust. Normally, this would have resolved any conflict of interest, because the trust assets could not be used for any other purpose.
But the court found that because Prudential had to fund the trust to keep it solvent, this provided a basis for a financial conflict of interest. The more benefits that were paid out, the more contributions Prudential would have to make to the trust. Conflict of interest would be a factor to consider in determining whether Prudential’s denial of benefits was reasonable.
Guidelines for Determining Procedural Bias in Long-Term Disability Case
The court also determined that it would have to consider procedural bias in the review process. Signs of a biased review could include:
- Failing to follow a plan’s notification provisions (Lemaire v. Hartford Life & Acc. T. Co.)
- Relying on the opinion of a non-treating physician over the opinion of a treating physician without giving a reason for doing so. (Kosiba v. Merck & Co.; Ricca v. Prudential Ins. Co. of Am.)
- Conducting self-serving paper reviews of medical files and relying on favorable parts while discarding unfavorable parts in a medical report (Post)
- Denying benefits based on inadequate information and lax investigatory procedures, (Porter v. Broadspire W.D. Pa. 2007)
- Ignoring the recommendations of an insurance company’s own employees (Post)
How would Prudential measure up against these factors? The Court would review the medical record that was available to Prudential at the time it made its final decision to terminate Morgan’s disability coverage.
Prudential’s Initial Review for Long-Term Disability Benefits
Morgan’s claim was initially evaluated on September 28, 2006. In the records provided by Morgan’s treating physicians, there was a mental health status examination conducted on May 20, 2006. Morgan’s neuropsychiatrist reported that Morgan had a major depressive disorder. This diagnosis was confirmed by other mental status examinations which had been conducted between 2005 and 2006. Morgan’s primary care physician reported on October 3, 2005 that anxiety was one obstacle that was preventing him from returning to work at Prudential. Morgan’s neurologist reported on February 9, 2006, that she suspected Morgan’s medical problems were connected to depression and lack of sleep. Yet another psychologist who was treating Morgan indicated that he had an anxiety disorder.
It was based on this information that Prudential reached the conclusion that Morgan’s functional impairment was primarily caused by depression and anxiety.
Prudential’s Reevaluation for Long-Term Disability Benefits
During a July 2, 2007 reevaluation of updated medical records, Prudential’s physician reviewer found that a September 16, 2006 neuropsychological evaluation still showed significant psychological deficits. There were records that Morgan was being treated with Zoloft and Cymbalta. There was also a December 4, 2006 letter that reported Morgan’s neuromuscular complaints, finding that his depression could not explain their existence. There were also records from December 29, 2006, February 9, 2007, and March 23, 2007 from the doctor who diagnosed him with fibromyalgia.
Prudential’s physician reached the conclusion, without citing medical authority for doing so, that fibromyalgia “rarely prevents the claimant from performing light or sedentary work.” In his opinion fibromyalgia was unlikely to cause continuous impairment.
This review was followed by a final review on March 11, 2008. Additional treatment notes regarding Morgan’s fibromyalgia treatments were now present in the record. These included notes from office visits on May 24, 2007, September 27, 2007, and January 31, 2008. Morgan’s doctor noted that he had some good days and bad days, and on one visit had 18 of 18 fibromyalgia tender points, while on the other two displayed 14 out of 18.
Prudential’s physician concluded that based upon these updated medical records Morgan was not sufficiently impaired “from any physical condition” that would prevent him from performing light or sedentary work. Based on this conclusion he recommended that Morgan be further evaluated. He recommended a functional capacity questionnaire be completed by Morgan’s rheumatologist identifying any physical obstacles that might prevent him from returning to work. He also recommended an independent medical examination (IME) by a rheumatologist, and surveillance.
Morgan’s rheumatologist completed the functional capacity questionnaire as requested. He verified that Morgan was unable to work full or part time because he could not stand or walk for more than 5 min. at a time, or sit for more than 10 min. at a time. Among the other limitations that he reported were Morgan’s inability to lift 20 pounds at any time, and his recommendation that he only lift 10 pounds occasionally. He also reported that Morgan have a limited ability to stoop, kneel, or reach overhead.
Prudential also ordered the IME, which occurred on May 5, 2008. This physician gave his opinion that Morgan did not suffer from a functional abnormality caused by musculoskeletal disease and also gave his opinion that Morgan’s chronic pain was “not documented by any objective findings.” This physician made it clear that he was unable to determine whether or not Morgan’s disability was related to anxiety or depression.
When, on May 22, 2008, Prudential advised Morgan that they were going to terminate his benefits, the disability plan reported that the physician conducting the IME and the physician reviewing his records had both reached the conclusion that his disability was the result of depression and anxiety.
When Morgan appealed on August 12, 2008, he provided three updated letters from his treating physicians. Two of his doctors clearly diagnosed his condition as fibromyalgia, and his treating neuropsychiatrist concluded that his anxiety was secondary to his fibromyalgia. It was the fibromyalgia which was preventing him from working.
When Prudential hired a board-certified rheumatologist to review Morgan’s medical records, the rheumatologist reached the conclusion that he did have fibromyalgia, but disagreed with his physicians that he was disabled as a result of the disorder. He pointed to “the absence of motor weakness, loss of muscle strength and tone, abnormalities in station and gait… [or] any focal neurologic abnormalities” as support of his conclusion.
Based on this physician’s conclusions, Prudential denied Morgan’s appeal. Prudential agreed that he did have fibromyalgia, but the long-term disability insurance plan concluded that this was not the cause of his functional impairment.
Court Considers Whether Medical Records Support Long-Term Disability Caused by Fibromyalgia
The court had to consider these same medical records to determine whether or not Prudential’s conclusion was reasonable. Was Morgan’s disability caused by mental illness, in whole or part? Or was his primary disability fibromyalgia, which caused anxiety and depression? The answer to these questions would determine whether or not Prudential’s decision was reasonable. Even if his mental illness contributed to his physical condition, the court would find Prudential’s decision was unreasonable, because this would place the court in a situation where it would always have to rule that someone who suffered from anxiety or depression as the result of a physical condition could not qualify for benefits based upon the physical condition.
Because Prudential concluded that Morgan’s mental illness caused his disability independently of his fibromyalgia, the court looked at whether the medical records supported this conclusion. This meant that the court compared how Prudential weighed the conclusions of the physicians it hired, versus the opinions of Morgan’s treating physicians.
First, the court found that the doctor, whose opinion was given the most weight, was neither a psychiatrist nor a rheumatologist, yet Prudential concluded that he had the ability to determine that Morgan’s anxiety and depression, not fibromyalgia caused his impairment.
When the court looked at the conclusions drawn from the IME, it found that the rheumatologist had ignored the fact that fibromyalgia is not a disease; it is a syndrome. In requiring the presence of an “organic muscular skeletal disease” to explain Morgan’s pain, he failed to recognize the nature of fibromyalgia. Thus his analysis produced erroneous conclusions.
The court had found in Steel that “requiring objective evidence of fibromyalgia would arbitrarily and capriciously eliminate all disability claims based on the disorder.” And Prudential had already been warned in its case with Kuhn that the long-term disability plan could not require physical findings or objective evidence of fibromyalgia. To rely on the fact that Morgan had no objective findings to support his fibromyalgia was arbitrary.
Prudential Abused Its Discretion – Must Reinstate Long-Term Disability Benefits.
The court found that Prudential had clearly abused its discretion and reached an arbitrary conclusion when it chose to terminate Morgan’s long-term disability benefits. As a result the court granted summary judgment to Morgan and denied Prudential’s motion for summary judgment on its behalf.
This case once again highlights how important it is to contact a long-term disability attorney that understands fibromyalgia claims.