Evidence suggesting a mistake in diagnosis, lack of detail, and unexplained contradictions are not fatal to LTD claim
In a case decided by the Seventh Circuit Court of Appeals this month, Sun Life initially approved Patton's long-term disability benefits, but discontinued them a year later. It found him able to perform his job as a truck driver in light of his training for an even more physically stressful career as a paramedic and a bizarre series of contradictory letters from his orthopedic specialist, first claiming that Patton was unable to work, then indicating he was, then finally reversing course again and indicating that he was unable to work.
Patton sued for the discontinued benefits under the Employee Retirement Income Security Act of 1974 (ERISA). Sun Life moved for dismissal of the case and the district court granted the motion. However, the Seventh Circuit reversed the dismissal.
Patton's knee injury interfered with his job as a truck driver, he stopped working and after the waiting period submitted a long-term disability claim statement to Sun Life. He attached a Sun Life Attending Physician's Statement form filled out by Dr. Ambrose indicating that Patton could not drive truck because of permanent restrictions on lifting, climbing, squatting, and sitting with knees flexed.
Sun Life questioned Dr. Ambrose about why he provided Patton with a release to start Paramedic's training which would be more strenuous than driving truck. Dr. Ambrose responded that Patton was released without restrictions. Armed with this letter, Sun Life cut off Patton's benefits on the basis that paramedic work was as demanding as truck driving and that Ambrose had revealed that Patton was no longer disabled.
Patton filed an administrative appeal and presented another letter from Dr. Ambrose, this one stating that Patton had severe premature arthritis of the left knee which prevented him from depressing and releasing a mechanical clutch of a tractor trailer rig.
Sun Life referred the case to an orthopedic specialist who opined that, “many people with medial facit arthritis can drive a truck doing deliveries and only the test of time would be able to determine its suitability ... to the degree and duration.”
Sun Life argued to the court that Ambrose's most recent letter was a “one-paragraph conclusory statement, unsupported by any medical evidence, clinical data, or office notes,” and failed to explain the basis for the conclusion. The Seventh Circuit held that such naked assertions are indeed insufficient by themselves, but Ambrose's letter did not stand alone: the record also included Ambrose's comparatively detailed diagnosis, his opinion as to Patton's condition, his prognosis and the resulting limitations he faced. It was detailed enough for Sun Life, the court opined, which initially approved benefits after receiving it, and it was detailed enough for the federal courts, since “even brief expert reports will suffice at the summary judgment stage.” The court further concluded that Ambrose’s two letters—while not identical in all details such as inability to drive a truck because of the stress of working the clutch in contrast to limits on stooping, lifting and sitting with knees flexed- they are generally consistent and together present a coherent opinion that Patton's knee leaves him unable to drive a truck. The court also found it ironic that Sun Life attacked Ambrose's one letter as terse and conclusory when the other letter it claimed decided the case was still less detailed.
The Seventh Circuit decided that the case should not have been dismissed for reasons as follows:
There is no extrinsic evidence of mistake; no one has testified as to why the letter was sent if it was not true. But that is not fatal to Patton's claim in light of the intrinsic evidence suggesting mistake-the detailed April 25 diagnosis, the subsequent May 12, 2004 letter reaffirming that diagnosis, the lack of detail in the March 9, 2004 letter and the unexplained contradictions between the various communications. Some of Ambrose's messages to Sun Life contain either errors or lies, but reasonable factfinders could locate them in different places. . . . The jury could go either way in the absence of the clarification; why should it be unable to believe the clarification? Ambrose's letter would be more powerful if it explained why he had previously taken inconsistent positions-an omission perhaps not the fault of Patton or his lawyer, given that as far as we know during the ERISA administrative proceeding, Patton lacked the ability to compel Ambrose's testimony or cross-examine him.
Inconsistencies and ambiguities in your doctor’s reports to your LTD carrier obviously should be avoided. (see, 9/6/06 Blog posting, How to Prove your Disability to the Insurance Company, Alan Olson) However, the Patton case provides that a person suffering from a long-term disability is entitled to a complete factual determination in a court of law even when the treating doctor’s statements are inconsistent or vague. The Patton case is a prime example of why it’s important to have a disability benefits attorney involved in your case from the beginning in order to protect your ERISA rights and avoid bad faith denial of your long-term disability benefits.
Alan C. Olson practices disability law from his offices in New Berlin, Wisconsin, and throughout the United States. AOlson@Employee-Advocates.com
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