What about the unfortunate employee who is covered by a disability policy but can't satisfy the insurer's demand for objective proof? Claims for disability benefits made by people who suffer from chronic pain and fatigue syndromes are often denied for lack of objective medical evidence. Because chronic fatigue syndrome and fibromyalgia cannot be verified by objective medical tests, these conditions pose a challenge for long-term disability benefits law. This problem is being fixed in our federal courts under the Employee Retirement Income Security Act of 1974 (ERISA). ERISA protects employees who have been improperly denied their long-term disability benefits.
In one recent case, a woman suffering from chronic pain syndrome, Cindy, could no longer do her job and filed a claim for long term disability benefits with her employer's insurance company. The insurance company's doctor agreed that Cindy suffered from, "significant subjective pain and fatigue." He found, however, that her impairment was "mild" based on the absence of any "objective medical findings to support a more significant impairment". Cindy's disability benefits were denied based on the plan administrator's rationale that, "besides self reported complaints, there are essentially no objective medical findings to support the pathology in the musculoskeletal or neurological systems".
Fortunately, Cindy got herself a good disability benefits lawyer and sued the pants off of this ignorant insurer. Cindy recovered all of her benefits, interest, attorney fees, and expenses under ERISA. The Court found that it was an abuse of discretion for the plan administrator to ignore the claimant's self-reported symptoms of chronic and disabling pain. "It appears the plan administrator simply refused to consider her subjective complaints as legally sufficient evidence. However, a plan administrator may not deny benefits simply because the only evidence of a disabling condition is subjective evidence."
In a similar case under ERISA, the insurer explained in its notice terminating benefits that, "stress is a subjective factor which cannot be correlated" with the objective medical evidence needed to establish total disability. The Court disagreed, finding that, "an inability to cope with stress can disable a person from performing his or her regular occupation, even if the person can still perform other work". The Court concluded that a disability that is stress-related therefore does not preclude him from recovering plan benefits under ERISA.
Cases such as these are by nature very fact-oriented and the Courts recognize that laboratory tests or similar diagnostic procedures will not always be necessary to substantiate a claim of disability, as certain disabling conditions are not susceptible to such objective evaluations. As stated by the Federal Rules of Evidence, "proof" is "evidence sufficient (or contributing) to establish a fact or produce belief in the certainty of something." This definition makes no distinction between subjective and objective evidence, so either will do.
It would defeat the legitimate expectations of plan participants to require those with chronic pain or fatigue syndromes to make a showing of clinical evidence of the cause, when such clinical proof does not exist. To require such clinical proof would mean that chronic pain and fatigue could never be shown to be totally disabling. Fortunately, the Courts and disability benefits lawyers are now wise to these callous tactics by the insurance companies. Help is finally on the way for those disabled who have been denied their long-term disability benefits!
Alan C. Olson practices employment law in New Berlin, Wisconsin. AOlson@Employee-Advocates.com
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