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Federal judge finds LTD claimant’s CFS, fibromyalgia disabling

In our last post, we talked about the increasing understanding of chronic fatigue syndrome, a disease that presents unique challenges in a long-term disability claim. As we wrote, while the symptoms of CFS are subjective, rather than being objectively provable via medical testing or observation, research is beginning to uncover subtle physical changes associated with CFS patients. 

Perhaps as research improves, reliable objective medical traits of CFS will be discovered, but for now, there are no reliable scans or lab tests to objectively prove the disease is present.

Court reverses LTD termination 

An April 4 U.S. District Court, Central District of California, decision explains how CFS claims should be analyzed given the lack of objective evidence. It also discusses fibromyalgia, another disease without objective medical proof, but with a myriad of subjective symptoms, especially pain. 

In Cochran v. Reliance Standard Life Insurance Company, available on Westlaw at 2018 WL 1725650, the judge reinstates long-term disability benefits that the insurer had terminated, saying that Cochran was no longer disabled from CFS and fibromyalgia. 

The administrative record was more than 2,000 pages long, mostly consisting of medical records, which the opinion summarizes in detail. The court performed a “de novo” review under ERISA, meaning that, rather than deferring to the insurance company’s decision, the judge performed her own independent analysis of the record, the insurance policy and the law, and made her own decision that the claimant continued to be disabled and should not have been terminated. 

Strong language about subjective symptoms 

The judge writes eloquently that a claimant must not be required to prove a subjective complaint (unmeasurable or not subject to proof by medical test or scan) by objective evidence, when the diseases in question — here CFS and fibromyalgia — are not objectively provable. Forcing objective proof when it cannot exist is an abuse of discretion, as well as arbitrary and capricious, writes the court. 

In this case, doctors who performed independent medical examinations or IMEs did just this. They discounted Cochran’s reported symptoms because they found only objectively normal clinical observations — when objective findings are not possible to show the existence of these diseases. 

Instead, the court writes, “disability claims based on fibromyalgia and [CFS] may be grounded in subjective evidence and treating physician records.” 

The judge quotes the U.S. Court of Appeals for the Ninth Circuit (the federal circuit controlling California federal courts) as saying that while an insurer has an interest in preventing payment of a claim based on subjective illness when the claimant may be lying about the unmeasurable symptoms, the claimant has just as much interest in seeing that the insurance company does not wrongly deny such a claim by requiring objective proof to save money.

 

 

 

 

 

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