Last week, long-term disability benefits claimant "Kelly" won her case after a trial against MetLife. Kelly's claim was supported by her physician, Dr. Michael Flaningam, who diagnosed Kelly as having fibromyalgia, with a secondary diagnosis of fatigue.
Fibromyalgia Criteria
According to the American College of Rheumatology, the criteria for classification of fibromyalgia are:
(1) a history of widespread pain, and
(2) pain in 11 of 18 tender point sites.
Dr. Flaningam asserted that Kelly "has total body pain, typically in the muscles, but sometimes in the joints. She is tired all the time and has difficulty concentrating." Dr. Flaningam noted: "I'm skeptical she'll ever be able to work on a daily basis or more than several hours straight."
Claims Administrator Must Let Claimant Know Specifically What Information is Needed
The Ninth Circuit (federal courts of Alaska, Arizona, California, Hawaii, Idaho, Nevada, Oregon, Washington, Guam, and the Northern Mariana Islands) has clearly held that it is the responsibility of the claims administrator to have a clear dialogue with plan participants and let them know specifically what information is needed. In the present case, Kelly repeatedly requested guidance on the type of evidence MetLife sought. Despite Kelly's specific requests, MetLife never gave her a description of any additional material or information that was necessary for her to perfect the claim, and do so in a manner calculated to be understood by the claimant. The Court held that "MetLife cannot now argue that it was [Kelly's] responsibility to guess at the appropriate objective measurement, if there is even one available."
Kelly also argued that MetLife selectively chose to review her claim as though her job was sedentary despite the fact that MetLife representatives first classified her job as "medium," and then changed it to "light." In other words, MetLife did not have a consistent classification for Kelly's job. The Court concluded that MetLife's inconsistent reporting of the level of her work directly affected the review. For instance, it is not clear whether MetLife's reviewing doctor would have come to a different conclusion if she knew that Kelly's occupation was then categorized as light.
MetLife's Decision to Deny Benefits 
Turning to MetLife's actual decision to deny Kelly's claim, the Court relied on prior case law to find that there is no "objective" method for measuring pain. "Disabling pain cannot always be measured objectively [and] individual reactions to pain are subjective and not easily determined by reference to objective measurements." The Court found MetLife's request for "objective" evidence particularly problematic in light of the fact that Kelly's basic conditions, fibromyalgia and fatigue, are inherently resistant to object verification. In fact, the Ninth Circuit has stated that fibromyalgia is "entirely subjective" and, "fibromyalgia's cause or causes are unknown, there is no cure, and, of greatest importance to disability law, its symptoms are entirely subjective. There are no laboratory tests for the presence or severity of fibromyalgia."
Here, MetLife never disputed Kelly's diagnosis of fibromyalgia. Instead, MetLife denied Kelly's claim on the basis that her pain did not limit her from engaging in sedentary employment.
MetLife Failed To Prove Malingering
MetLife argued that Kelly showed signs of malingering because she refused to take the medication. However, MetLife did not point to any evidence to show that Kelly's adverse reaction to Lyrica and other medications would discredit her diagnosis or prove that she was not disabled. MetLife also argued that Kelly was able to work because she refused to take weaker pain medications such as ibuprofen. MetLife's claim was unpersuasive because at various points in Kelly's medical history, one of Kelly's doctors prescribed her treatments other than pain medication, such as 20 mg of Feldene and supplements such as flaxseed oil and borage oil, and Kelly's other doctor noted that "I'm not sure that any medicine will bring about significant relief." In fact, MetLife's own reviewing doctors acknowledged that Kelly was "receiving appropriate care and treatment," Kelly was "compliant with the treatment plan," and that "necessary" medications were "being prescribed [ ] for symptom palliation and control of symptoms." Also, MetLife did not take issue during the administrative appeal process with Kelly's reluctance to take medication-but only did so after Kelly filed suit.
MetLife's Doctors Did Not Examine Kelly Personally
Further, at no point did any doctors contracting to work for MetLife engage in an in-person examination of Kelly. Though the lack of an in-person examination is not determinative, it is a relevant consideration, especially with respect to conditions that are not susceptible to objective verification, such as fibromyalgia.
Finally, at trial, MetLife conceded that there is no objective test to measure Kelly's inability to function due to pain. Accordingly, MetLife was requesting objective evidence measuring Kelly's pain despite the fact-well-established in the caselaw- that there is no objective measure for such pain. In essence, then, by requesting "objective" evidence, MetLife "turn[ed] down [Kelly's] application for benefits based on [Kelly's] failure to produce evidence that simply is not available."
This court decision is encouraging to our firm's clients who have been arbitrarily denied their long-term disability benefits by carriers like MetLife that use such capricious tactics.
Alan C. Olson practices disability law from his offices in New Berlin, Wisconsin, and throughout the United States. AOlson@GetMyLTDbenefits.com
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