Court: District Court, N.D. California; January 21, 2014; Federal District Court
In the appeal regarding the denial of disability benefits under an ERISA plan, the Court addressed cross-motions for judgment as a matter of law following a bench trial held on December 6, 2013. The Court granted in part and denied in part the Plaintiff's motion while denying the Defendant’s motion.
Plaintiff Debra Eisner, employed since 1991 as an Administrator at Surgical Care Affiliates, ceased working on March 15, 2010, due to multiple health issues, including chronic fatigue syndrome and fibromyalgia. She filed a claim for Long Term Disability (LTD) benefits with The Prudential Insurance Company in July 2010.
The LTD Plan defines disability as being unable to perform the material and substantial duties of one’s regular occupation due to sickness or injury, under the regular care of a physician, and experiencing a 20% or more loss in monthly earnings. After 24 months, coverage requires the claimant to be unable to perform any gainful occupation for which they are reasonably suited. The Plan also stipulates that a continuous disability must persist throughout a 180-day elimination period, with limitations on benefits for disabilities based primarily on self-reported symptoms, which previously did not apply to fibromyalgia as determined by an earlier court order. Prudential denied Eisner’s claim on November 23, 2010, and her appeal of that denial on February 28, 2012, leading to her subsequent appeal filed on March 12, 2012.
Prudential evaluated the Plaintiff's disability claim by reviewing medical records from three treating physicians: Dr. Marian Beshara (primary care), Dr. Geetha Paladugu (psychiatrist), and Dr. Richard Munson (allergist). The Plaintiff appealed the initial denial of benefits by submitting additional evidence, including a report from the Pacific Fatigue Laboratory and an independent medical examination by Dr. Stuart Silverman. Prudential also collected further records from Drs. Munson and Paladugu during the appeal process.
Dr. Beshara's records, spanning from 2008 to 2011, document the Plaintiff's ongoing struggle with chronic fatigue and fibromyalgia. On January 18, 2008, Dr. Beshara noted the Plaintiff's worsening fibromyalgia symptoms and initiated treatment with Lyrica. By April 2008, despite a colonoscopy-related surgery, the Plaintiff continued to experience significant fatigue. Subsequent visits indicated fluctuations in her condition; while her fibromyalgia was initially well-controlled, her fatigue persisted. Dr. Beshara noted the Plaintiff's increasing stress and depression related to her chronic fatigue, leading to several medication adjustments. By late 2008, the fatigue was attributed to multiple factors, including the aftermath of her surgery. In early 2009, the Plaintiff reported some improvement through diet and exercise, but by February, chronic fatigue remained a significant issue. The last record from October 4, 2010, indicated ongoing chronic fatigue syndrome, with the fibromyalgia pain under control, but the fatigue showed little improvement.
Dr. Beshara's February 2011 visit highlighted the patient's ongoing chronic fatigue, confirming her disability status. Despite Prudential's claim that she was "enjoying her time off," the context of Dr. Beshara's notes indicates agreement with the patient's disability. Medical records from Dr. Munson, though largely illegible, documented the patient's persistent headaches, pain, and fatigue due to fibromyalgia from 2009 to 2010. Dr. Munson submitted an Attending Physician Statement citing "severe fatigue" as the reason for the patient's inability to work and recommended continued leave from her job since June 2010.
Dr. Paladugu's evaluations began in March 2009, noting symptoms such as depressed mood, low energy, and irritability. He assessed the patient as severely impaired in personal relationships and physical health, with mild impairment in work. Progress notes indicated ongoing exhaustion and medication for depression and anxiety. In June 2010, after a brief return to work, the patient reported being unable to function due to fatigue. By September 2010, fatigue and low energy persisted, leading to a prescription for Ritalin. Subsequent notes in December 2010 and May 2011 reiterated the patient's fatigue, with the last note from August 2011 mentioning her father's death and ongoing anxiety, though pain levels were reported as under control.
The Pacific Fatigue Laboratory's evaluation on June 13-14, 2011, assessed the patient's metabolic and cognitive functions through exercise testing and found her oxygen consumption to be moderately to severely impaired, along with abnormal pulmonary function and recovery time indicative of significant physical stress response. The report concluded there was no evidence of malingering in the patient's maximal effort.
Plaintiff experienced "extreme fatigue and increased joint pain" after a re-test, accompanied by cognitive confusion. A report indicated that the physiological abnormalities observed were not due to poor effort and stated that most job tasks would require more energy than the Plaintiff could sustain, highlighting both fatigue and functional limitations. The report was substantiated by extensive references on chronic fatigue syndrome and exercise stress tests.
Dr. Stuart Silverman, a professor of medicine and rheumatology, conducted an Independent Medical Examination on June 30, 2011. He noted that Plaintiff had been diagnosed with fibromyalgia since 1995 and experienced pain in multiple areas, with only partial relief from medication. Following a colonoscopy in 2008, she developed fatigue. At the time of evaluation, her daily routine involved minimal activity, and she reported severe fatigue rated at 10/10, alongside symptoms of generalized anxiety disorder and probable depression. Cognitive impairments included memory issues and difficulty concentrating.
Dr. Silverman's examination confirmed fibromyalgia through an eighteen-point trigger test, and he concluded that Plaintiff is totally disabled due to unpredictable fatigue, pain, and cognitive dysfunction. He deemed her reports of pain and fatigue credible and stated she could not return to her previous job as a nursing administrator.
In support of her appeal for disability benefits, Plaintiff and her significant other submitted statements detailing her health's impact on her life. Plaintiff recounted her history of chronic fatigue syndrome and Epstein-Barr Virus, diagnosed at age thirty-one. This illness affected her personal life, leading to a postponed marriage and eventual cancellation of her engagement. She initially received disability benefits in 1988 but returned to work full-time until March 2010.
From 1989 to 2010, the plaintiff experienced persistent symptoms that fluctuated in intensity, significantly impacting her daily life, allowing her to only manage work, eat, and sleep. Diagnosed with fibromyalgia in 1995, she maintained a progressive work history, starting as a Business Office Manager at Surgical Care Affiliates in 1991 and rising to Facility Administrator by 2000, earning an annual salary of $120,000 plus bonuses. Key turning points in her condition included a colonoscopy and a broken rib, which led to difficulties in maintaining her work schedule and required her to arrive late. Despite a previously active role requiring interaction with medical staff, she felt she would have failed without colleague support. Her self-esteem was tied to her job, but escalating fatigue and pain forced her to stop working.
Her relationship with Leonard Sigdestad began in 2007 when she was relatively healthy, but her condition deteriorated, limiting their social activities and requiring Sigdestad to provide increasing care. Family visits often saw her confined to bed, and activities like skiing became untenable due to fatigue. Sigdestad described her prior vitality and enthusiasm, contrasting it with her current state, where she feels unwell 80% of the time and finds normal activities, such as dining out, exhausting. He noted a significant shift in her emotional well-being, reporting that she now feels bad 29 days a month compared to only 1 day previously.
Prudential, after receiving the disability claim, conducted a file review by Nurse Mashelle L. Krier, which led to denial of the claim. Subsequent medical records prompted Prudential to seek independent reviews from rheumatologist Dr. Mark Borigini and psychiatrist Dr. Antoinette Aceñas.
Nurse Krier reviewed the Plaintiff's medical file and documented her assessment in a SOAP note dated November 22, 2010, stating she did not believe the Plaintiff had any physical restrictions or limitations. Krier examined records from multiple doctors and noted that the Plaintiff's condition did not deteriorate upon leaving work, despite some increased pain related to fibromyalgia and an adjustment in medication. The reported symptoms, including sleep quality fluctuations, concentration issues, and pain, were not significantly different from prior assessments since March 2009. Krier concluded there were no restrictions or limitations linked to the Plaintiff's various diagnoses, including fibromyalgia and chronic pain conditions. She recommended several follow-up actions to evaluate the Plaintiff's functional capacity, which Prudential did not pursue, subsequently denying the Plaintiff's claim on November 23, 2010, based largely on Krier’s findings.
Dr. Borigini, a board-certified rheumatologist, conducted an independent review of the claim on February 7, 2012, concluding that the Plaintiff's pain was generally controlled and that she was enjoying time off, indicating she was not disabled. His report found no neurological or joint issues documented in the medical records, attributing the main concern to fatigue. Dr. Borigini dismissed a report from the Pacific Fatigue Laboratory, stating that the exercise study was not relevant to fibromyalgia evaluation and suggested a cognitive-behavioral model could explain the Plaintiff's condition.
In a supplemental review on March 13, 2012, Dr. Borigini clarified his findings in response to follow-up questions from Prudential. He noted a lack of joint or muscle pathology that would limit physical functioning and deferred assessments regarding cognitive dysfunction and fatigue to specialists in neuropsychology and mental health, acknowledging the Plaintiff's symptoms but indicating no clinical or laboratory evidence to explain them.
Dr. Borigini was questioned about the existence of more recent medical opinions on the validity of tests from the Pacific Fatigue Laboratory, beyond a fifteen-year-old study he referenced. He indicated that he was unaware of any robust literature contradicting his views, suggesting consultation with an oxygen consumption expert, as this area is outside a rheumatologist’s training. He did not address the specific results of the exercise testing or explain why they did not indicate functional impairment.
When asked to consider statements from the Plaintiff and her partner, Dr. Borigini stated that his opinions on disability are based on clinical measures and the claimant's reported history, concluding that the findings did not support a claim of permanent disability.
Dr. Aceñas, a psychiatrist, reviewed the claim file and produced a report on February 7, 2012, stating that the Plaintiff showed no psychiatric impairment that would necessitate restrictions or limitations between March 15 and September 11, 2010, and thereafter. His assessment was based on Dr. Paladugu's notes, which indicated the Plaintiff was stable on her medications, and he determined that her anxiety and depression were not severe enough to qualify as impairments.
In a follow-up report on March 19, 2012, Dr. Aceñas reaffirmed his earlier findings, acknowledging limitations identified by the Plaintiff and her partner but clarifying they were unrelated to any psychiatric condition.
The Plaintiff's appeal for her disability claim was denied on February 28, 2012, based on the evaluations from Nurse Krier, Dr. Borigini, and Dr. Aceñas. The denial was rooted in the conclusion that the Plaintiff's subjective impairment reports were not substantiated by diagnostic and clinical testing, asserting that the medical evidence did not justify any medically supported restrictions or limitations in her physical, psychiatric, or cognitive functions.
The Employment Retirement Income Security Act (ERISA) allows claimants to seek federal recovery of benefits due under an ERISA plan, as outlined in 29 U.S.C. 1132(a)(1)(B). The parties have agreed to a de novo standard of review, which involves a Rule 52 bench trial based on the administrative record, where the court evaluates whether the plaintiff is disabled. The plaintiff must demonstrate, by a preponderance of the evidence, that she was disabled as defined by the plan.
Fibromyalgia poses unique challenges in disability law due to its unknown causes, lack of a cure, and entirely subjective symptoms, which necessitate ruling out other diseases through objective tests that do not confirm fibromyalgia itself. The condition is classified as physical and is diagnosed using criteria set by the American College of Rheumatology, with standard clinical examinations like the eighteen-point trigger test recognized as valid diagnostic methods. Similarly, chronic fatigue syndrome lacks objective laboratory tests, relying instead on symptom comparison to CDC guidelines and comprehensive medical history reviews.
The Ninth Circuit has consistently held that the absence of objective physical findings alone cannot justify the denial of disability benefits. A plan's reliance on normal diagnostic results, despite credible evidence of impairment from fibromyalgia or chronic fatigue syndrome, constitutes an abuse of discretion. The court acknowledges the complexities and potential for abuse in claims related to these conditions, recognizing that both claimants and plans may have incentives to misrepresent their situations.
Medical conditions often rely on subjective reports of symptoms for diagnosis, and some cannot be objectively confirmed until autopsy, making it inappropriate for a disability insurer to require objective proof such as blood tests for recognized conditions without such evidence. In the Salomaa case, the Ninth Circuit awarded benefits to a claimant with chronic fatigue syndrome, criticizing the disability plan for relying on internal file reviews rather than consulting the claimant's treating physicians, who determined the claimant was disabled. The only opposing opinions came from physicians hired by the insurance company who did not examine the claimant.
The current case mirrors Salomaa, as the medical evidence supports the Plaintiff's disability under the Plan's terms. Prudential acknowledges the Plaintiff’s diagnoses of chronic fatigue syndrome and fibromyalgia but argues her condition was stable and controlled when she ceased working, relying on selective quotations and misrepresenting her symptoms. Treating physicians noted ongoing fatigue and exhaustion, with the Plaintiff's condition worsening significantly due to medical issues leading to functional impairment.
Statements from the Plaintiff and her significant other corroborate her claims. Although the pain was sometimes controlled, the Plaintiff consistently faced difficulties due to fibromyalgia, and her fatigue remained unstable. Prudential's reviews, conducted by consultants who never examined the Plaintiff, lack credibility compared to the treating physicians’ records, which courts typically favor. The absence of direct examinations of the Plaintiff by Prudential’s physicians diminishes the weight of their opinions, particularly for fibromyalgia, which requires patient-reported symptoms for proper evaluation.
Reports from Nurse Krier and Dr. Borigini are deemed less credible as they require diagnostic confirmation for a condition that lacks such evidence. The Plan cannot deny Plaintiff's claim solely due to her physician's inability to provide physiological proof of her condition, which is inherently unconfirmable. Dr. Borigini dismissed relevant objective evidence, including an eighteen-point trigger test and an exercise stress test, citing outdated authority and failing to analyze their results. He suggested a consultation outside his expertise rather than evaluating the evidence presented. Nurse Krier's conclusions were based on an incomplete record, as she did not consider key reports and statements, and her recommendation for further examination was ignored by Prudential. The Court found that the positions of Nurse Krier, Dr. Borigini, and Prudential set an unreasonable standard for claimants with fibromyalgia, which contradicts established case law that allows subjective evidence and treating physicians' reports to support disability claims. The Court concluded that credible evidence shows Plaintiff suffers from severe fatigue and fibromyalgia, rendering her unable to work.
The Court has determined, after a de novo review, that the Plaintiff qualifies as disabled under the Long-Term Disability (LTD) Plan for the entire elimination period and is entitled to receive disability benefits. The parties are instructed to meet within thirty days to discuss the appropriate amount of benefits owed to the Plaintiff for the "own occupation" period and to submit a proposed judgment that aligns with the Court's Order. The Court will not consider the "any occupation" term of the Plan, which pertains to benefits beyond the first twenty-four months of disability, as Prudential has not yet made a determination on that issue. Prudential is ordered to assess the Plaintiff's entitlement to benefits under the "any occupation" term within ninety days of this Order.
The most recent job description for the Plaintiff, dated March 13, 2001, aligns with a request made by the Vice President of Operations in June 2010 to the Plaintiff's allergist, seeking to evaluate her ability to perform her role as “Center Administrator.” The description provided is consistent with that of an "Administrator." Furthermore, it is noted that medical reviews for Prudential were conducted by MES Solutions, which has also provided review services for other insurance companies. The Court criticizes Hartford's reliance on non-treating physicians’ opinions without conducting physical examinations of the Plaintiff, arguing that this approach appears arbitrary and capricious, as Hartford should not disregard the findings of the Plaintiff's treating physicians in favor of its own consultants' assessments.
