Good News for ERISA Claimants that Suffer from Fibromyalgia, Chronic Fatigue Syndrome, or an Autoimmune Disease?

Is the Recent Opinion of Williams v. United of Omaha, 2013 U.S. Dist. LEXIS 141563 (N.D.Ala.)  (September 30, 2013) a Breath of Fresh Air for ERISA Claimants that Suffer from Fibromyalgia, Chronic Fatigue Syndrome, or an Autoimmune Disease?  ERISA claimants suffering from fibromyalgia, chronic fatigue syndrome, or autoimmune diseases that are difficult to diagnosis, often have an uphill climb in securing ERISA benefits from an insurance carrier.  Benefits are often denied on the basis that the symptoms are self-reported, that there is no “objective” evidence of the disease or ailment, or that the insured underwent with no apparent discomfort an IME (independent medical exam) or FCE (functional capacity exam).

These issues were recently addressed in the above opinion where the Court found that United of Omaha’s decision to terminate benefits after paying them for two years was de novo wrong. The Court called the insurance company to task over several different things which are discussed below.  First, although the vocational expert listed the insured’s occupation as “L” EDC, which would indicate it was a “light” exertion level, United of Omaha’s denial letter to Williams listed insurance sales agent as a sedentary exertion level position. The Court also found that the records and testimony of Williams’s treating physician, Dr. McLain, the Chief of Rheumatology at Brookwood Hospital, provided sufficient evidence supporting his diagnoses of fibromyalgia, rheumatoid arthritis, osteoarthritis, Sjogren’ssyndrome, and thyroid disease.

The Court further explained that Fibromyalgia is a disease like chronic fatigue syndrome with subjective symptoms such as pain generalized all over the body, fatigue, stiffness, disturbed sleep, and multiple tender spots; the symptom that distinguishes fibromyalgia from other rheumatic diseases is the existence of tender spots in 18 fixed locations  located throughout allfour quadrants of the body that cause a patient to flinch when pressed firmly. Sarchet v.Chater, 78 F.3d 305, 306 (7th Cir. 1996). Importantly, the Court noted that if it “were to require objective facts such as lab tests or an xray to support a diagnosis, no patient would ever be disabled based on fibromyalgia.

Next, the Court found the Plaintiff’s treating more credible than the insurance company’s paid reviewers.  I explained: ”While the Supreme Court held that ERISA administrators are not required to defer to treating physicians over reviewing physicians, the district court handling ERISA appeals may evaluate the weight of each doctor’s opinion based on the extent of the patient treatment history, the doctor’s specialization or lack thereof, etc. See Black & Decker Disability Plan v. Nord, 538 21 U.S. 822, 832 (2003). For a conditions as subjective and variable as fibromyalgia and rheumatoid arthritis, direct contact with the patient over a period of time would provide a more thorough opportunity to assess her credibility regarding level of pain and the true pattern of her abilities. Therefore, in the instant case, the court will focus heavily on the opinions and treatment records of Williams’s treating physicians such as Dr. Odi and Dr. McLain.

The Court also discounted a physical therapist’s evaluation, which had found the Plaintiff capable of performing certain sedentary work, because that evaluation, while providing information regarding what physical functions Williams could perform for three hours on a particular day, is not determinative of Williams’s work capacity; even the evaluator acknowledged that, given Williams’s fibromyalgia, a more accurate evaluation of her work tolerances would require a two-day evaluation to gauge her response on day two to the effects of day one testing, but no two-day testing was performed.

Interestingly, the Court indirectly hinted at the inherent conflict of interest that an Administrator operates under when it not only makes the benefits determination but also pays the claim.  The Court stated: “Extensive referrals and a bundle of paperwork are not necessarily indicative of reasonableness or unreasonableness on the part of the company. The paper trail could well represent a good company wanting to be thorough and to make a reasonable, well-informed decision. But, it could also represent a company’s less admirable wish to stop paying expensive but appropriate disability benefits and a commitment to keep hiring experts until it could cobble together the right opinions to appear to justify an unreasonable denial of benefits.

We are pleased with the well reasoned comprehensive opinion of Williams v. United of Omaha, 2013 U.S. Dist. LEXIS 141563 (N.D.Ala.)  (September 30, 2013 )that was just released and hope it marks the type of jurisprudence other federal Courts will use when reviewing ERISA benefit claims.

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