If you have a disability claim governed by the Employee Retirement Income Security Act (ERISA) that has been denied, chances are the claim administrator (usually an insurance company) has denied your claim on the basis that the medical evidence does not support functional limitations that would preclude you from being able to work.
Subjective Medical Conditions
Many times, claims for disability benefits are based on a purely subjective medical condition like chronic fatigue syndrome, fibromyalgia, migraine headaches, psychiatric claims (i.e., anxiety and depression), which are not susceptible to objective verification through diagnostic measures (i.e., x-ray, MRI, CT scan, electrodiagnostic studies, etc.). Physicians typically diagnose these conditions based upon the subjective complaints of their patients.
If a claim administrator is going to require that disability be proven by objective medical evidence, the policy insuring the group disability plan must include language explicitly requiring that the claimant’s disability be supported by objective medical evidence. The First Circuit has held that an ERISA plan may require objective medical evidence that supports the inability to work due to “the physical limitations imposed by the symptoms of such illnesses…” Boardman v. Prudential Inc. Co. of Am., 337 F.3d 9, 16 n.5 (1st Cir. 2003).
It is certainly easier to support limitations and restrictions preventing someone from being able to work when the medical condition(s) that is the basis of disability is supported by objective medical evidence. Nevertheless, this does not mean that disability can be established using subjective medical evidence when the policy does not specifically require objective medical evidence. Furthermore, district courts have held that it is unreasonable for a claim administrator to require that disability be supported by objective evidence when the medical condition is not susceptible to objective verification. Cook v. Liberty Life Assurance Co., 320 F.3d 11, 21 (1st Cir. 2003).
Subjective Complaints in Disability Claims
Obviously, when a claim is based upon a claimant’s subjective complaints, the claim administrator is forced to consider the credibility of the claimant. In evaluating the claimant’s credibility, the claim administrator will consider the extent of the claimant’s treatment history, medication prescription history, whether there have been medication side effects, and the specialization of the doctor caring for the claimant, etc. It is important that the claimant is being treated by a doctor who specializes in the condition at issue and there is other evidence that corroborates the disabling condition. The 9th Circuit Court of Appeal discussed this very fact in Salomaa v. Honda Long Term Disability Plan, 642 F.3d 666, 674-675 (9th Cir. 2011).
When claims are based upon subjective evidence, claim administrators will determine if there is conflicting information in the medical records and/or the other evidence in the file. For instance, sometimes the claim administrator will obtain video surveillance that shows the claimant engaging in activities that are inconsistent with the information provided by the claimant and the treating physician. It is vitally important that the claimant and the treating physicians provide claim administrators with consistent information. It is also important that the claimant avoid engaging in activities that treating doctors have advised against because it could result in a claim being denied.
Legal Help for ERISA Appeals
Having experienced attorneys help you perfect your ERISA appeals is critical to protecting your rights and benefits. Our team is here to help and will only take a fee if the claim is approved for benefits or the case is won in court.