In this recent case out of California, the Plaintiff previously worked in IT for the Capital Group Companies. However, he was forced to stop working on February 2, 2011, due to chronic fatigue and fibromyalgia. Through his employer, the former IT employee had long term disability coverage under a Policy with Reliance Standard. After applying for benefits, his claim was approved in August 2011 and ultimately paid through March of 2015. Unfortunately benefits after March of 2015 were denied as Reliance Standard believed he no longer satisfied the definition of disability. After numerous appeals were filed and numerous reviews conducted, a lawsuit was filed.
Ultimately, the Plaintiff was successful with the lawsuit, and the reasoning behind the Judge’s decision is quite interesting and provides helpful information to persons with disability claims.
It must be first pointed out that the Judge in this case reviewed the case under a De Novo Standard of Review. This means that the judge was able to consider the question as to whether the person was disabled as if he or she is the first person to do it. It allows the Judge to use his or her own judgment in deciding whether the claimant is disabled or not. Typically, in disability cases, the Judges do not have this much liberty. Judges are typically restricted to what is called an Abuse of Discretion Standard. In the Abuse of Discretion Standard, the judge usually only gets to decide whether there were “reasonable” grounds to support the decision made by the insurance company. If there were “reasonable” grounds, then the insurance company wins. So the Standard of Review makes a huge difference in these lawsuits. If you can get a De Novo review, your odds of prevailing significantly increase.
In this case, the Judge used a De Novo Standard of Review and because of this the judge actually allowed extrinsic evidence to be considered. Extrinsic evidence is evidence outside of the administrative record. The judge reviewing evidence outside of the claim file is very rare. However, there are limited circumstances where a judge can consider evidence outside the claim file. One of these circumstances being when the claim is about complex medical issues and the Court needs to look at the credibility of the medical experts. Another instance is evidence that the claimant could not have presented during the appeal process. In this case, the judge allowed himself the availability to review the Social Security’s disability determination. The Social Security Administration’s approval of the claimant’s Social Security Disability Claim could not have been presented during the appeal process as the Social Security Administration did not approve (or actually reapprove) his claim until September 2016, after the claimant’s final administrative appeal to Reliance Standard was filed. As such, the Judge found the decision relevant, though not binding, and considered the Social Security approval when determining whether the Plaintiff was disabled.
In addition to reviewing the Social Security decision, the judge also reviewed every record in the claim file. In reviewing all the records of the file, the judge took issue with the assessments Reliance Standard relied upon. Notably, the judge pointed out that each of Reliance Standard’s doctors all reported that the Plaintiff’s chronic fatigue syndrome had ceased, but the judge found this unsupported by the actual medical evidence. The judge also found fault with the Independent Medical Examinations (IME) conducted by Reliance Standard and the insurance company’s reviews due to the fact that they all demanded clinical confirmation (objective evidence) of a condition that cannot be confirmed through such tests. Thus, the judge afforded those reviews almost no weight. The Judge noted, “Courts have held that a plan cannot demand objective tests to establish a condition for which no objective tests exist.” The Judge even openly criticized one doctor who noted there were no signs of muscle atrophy. The Judge found this highly questionable as muscle atrophy is not one of the signs or symptoms of fibromyalgia.
In the end, the judge found the Plaintiff to be totally disabled through the medical records and opinions of the treating providers, noting that for claims based on fibromyalgia and chronic fatigue syndrome, they can be grounded in subjective evidence and treating physician records.
While this case was not handled by our office, we think it can be beneficial to those struggling to obtain long-term disability benefits. Keep in mind that some of the outcome was dependent on the fact that the Judge was afforded the possibility of a De Novo review and that the policy did not have an objective evidence requirement as some do. In the end, this case is a great outcome that can be used to support future claims against Reliance Standard and all disability insurance companies.
If you have any questions about your own disability claim, contact one of our attorneys at Dell & Schaefer for a free case evaluation.