Ms. Dana Kysztofiak worked as a Clinical Coordination Manager for HomeCare Maryland LLC. She was a registered nurse who stopped working in 2016 because of pain and other issues related to psoriatic arthritis and fibromyalgia. She claimed disability benefits through an ERISA plan with Boston Mutual Life Insurance Co. beginning December 29, 2016. Approximately four months after submitting her application, Boston Mutual began paying her $4,377.50 per month for disability benefits.
However, Boston Mutual determined that Ms. Kysztofiak was not disabled any longer in the Spring of 2018, and her disability insurance benefits terminated on May 25, 2019. She appealed through channels with her insurance carrier, and then started a lawsuit and appealed to the court when they denied benefits.
Fibromyalgia and Disability
Boston Mutual decided to terminate Ms. Kysztofiak’s long term disability benefits in large part because her treating doctor noted that she had “good control” of her psoriatic arthritis. They determined, then, that because her limitations were mainly due to fibromyalgia, she no longer qualified for benefits based on the language of the plan.
Fibromyalgia is a unique pain disorder that does not have any physical manifestations. It is difficult to “see” for the average person, and the only real way that doctors know that someone has this type of condition is due to their own subjective measurements of pain. Because there is no objective way to measure it, insurance companies sometimes balk at paying benefits for this reason.
Nonetheless, Ms. Kystofiak’s treating doctors diagnosed her with fibromyalgia, and her subjective complaints of pain were very severe. She even noted that she periodically had panic attacks and anxiety because her pain never stops. In a common test for fibromyalgia, her treating doctor indicated that she met “18 out of 18 tender points.” They concluded that her severe condition limited her activities of daily living significantly.
Reviewing the Insurance Company’s Decision
The Boston Mutual policy gave the insurance company discretion to interpret the plan provisions. This distinction is important because that means that the company is given more deference than it would otherwise have in deciding what the policy language means.
When the insurance company has this type of discretion, then the court’s review is based on “abuse of discretion” rather than a complete analysis of all of the facts. That also means that the court will only set aside the insurance company’s decision if it is unreasonable. The insurance company must have clearly reviewed the facts, applied “principled reasoning,” and relied on the real evidence in the case.
Providing “Objective” Evidence of Disability
One of Boston Mutual’s main arguments in denying Ms. Kystofiak LTD benefits was that she could not provide any “objective” evidence of her condition. However, if this was a true test of whether someone is considered disabled, then conditions like fibromyalgia would never be disabling because fibromyalgia does not manifest itself in any objective way.
In an earlier Fourth Circuit case, the court required that a patient present “objectively satisfactory” evidence of disability. In its ruling, the court explained that the terms “objectively satisfactory” and “objective evidence” are not the same thing. In making this point, it described some of the underlying symptoms of fibromyalgia, including:
- Significant pain and fatigue
- Stiffness of joints
- Disturbed sleep
- Inference with general abilities to carry on daily activities
In reviewing the symptoms, the court stated: “Put simply, no ‘objective evidence’ exists to prove that the rheumatic disease known as fibromyalgia exists. Yet, the subjective complaints of people living with fibromyalgia are sufficiently consistent and numerous to provide the medical community with ‘objectively satisfactory’ evidence that fibromyalgia is very real.”
The “tender points” test provides some objective measure. It tests 18 points across the body, and if 11 of those 18 points are tender, then a patient is more likely to be suffering from fibromyalgia. Nonetheless, those tender points are still reported only by the patient; there is no test or measurement that can definitively determine that a patient has fibromyalgia.
Instead of relying on what Ms. Kystofiak’s treating doctors stated regarding her limitations, Boston Mutual’s doctors made the mistaken assumption that anyone with fibromyalgia could perform sedentary work. While most fibromyalgia cases do not result in the inability to work entirely, there certainly are severe cases where working is not an option.
Ms. Kystrofiak’s testing results indicate that her doctors and other professionals did not believe that she was lying about her condition or in any way magnifying her symptoms. Instead, they certainly believed that Ms. Kystrofiak had fibromyalgia and it was severely debilitating for her.
Unique Issues with Pain Medications
Ms. Kystrofiak’s situation was also unique with regard to the pain medication that she was receiving. Her doctor prescribed her opioid medications for pain. However, other professionals noted in their review of her medical conditions and related treatment, that the opioids that she was taking would actually not be effective for fibromyalgia treatment.
She explicitly stated that still struggled significantly with pain, and the medications often had little effect. Eventually, she switched to medical marijuana as a way to deal with her pain.
In her appeal, the court did not think much of the opioid medications and fibromyalgia combination because the doctor prescribing the medication was sanctioned for overprescribing patients by the Maryland Board of Physicians. Unfortunately, Ms. Kystrofiak was simply a victim of that doctor’s “pill mill.”
Not every disability will come with “objective” evidence of a physical condition or defect. In some cases, simply having subjective complaints can be enough to show certain types of conditions, including fibromyalgia.
Although Dell & Schaefer did not handle this case, we understand that proving these more unique medical conditions can be challenging. If you need help with a similar claim, contact our office for a free consultation.