Sufferers of CFS or Fibromyalgia Cannot Be Denied Their Long-Term Disability Benefits by an Insurer Without a Specialist

In a recent court decision, the Long-Term Disability Insurer put great weight in the suggestion that letters by the disabled woman’s doctor were “contradictory”.  The Insurer argued that the doctor’s first letter diagnosed Chronic Fatigue Syndrome as the cause of the Claimant’s ailments, but in her second letter the doctor suggested her chronic fatigue was caused by sinusitis. 

After reviewing the letters, the Court did not find them inconsistent. In both letters the doctor opined that her patient suffered from a debilitating fatigue marked by a specific array of symptoms.  The first letter indicated those symptoms were consistent with Chronic Fatigue Syndrome.  The second letter did not deviate from this opinion but actually lent more evidence to a Chronic Fatigue Syndrome diagnosis.  The second letter also expanded on the details of the Claimant’s sinus problems suggesting the sinusitis may also have been responsible for the chronic fatigue.  “The expanded discussion of sinusitis in the second letter did not render it contradictory with the first letter”, the Court opined: “The letters are entirely consistent in one sense: they indicate the Claimant suffers from a debilitating fatigue.” 

The Court chastised the insurance company vehemently because, “instead of looking for contradictions, the Insurer should have considered the possibility that the Claimant suffered from a complicated medical problem that required further testing and examination.” 

The Court also properly laid blame on the Insurer for latching onto a single sentence indicating the Claimant was feeling a “bit” better after starting a new medication, but did not consider the medications the woman was taking or how these medications would affect her ability to work as an accounting supervisor. 

Finally, the insurance company provided no information about the qualifications of the individuals who reviewed the LTD benefits request.  The Insurer relied on its Disability Specialist but offered no evidence that the “specialist” had any medical training.  So, the Court reasoned, it is impossible to know whether the specialist for the LTD carrier was experienced with claims involving Chronic Fatigue Syndrome.  “In sum, it does not appear a qualified decision-maker reviewed her case, calling into question whether the Claimant received the process she was due.”  If the Insurer doubted the legitimacy of the disabled woman’s claims, it should have had outside experts examine her and attempt to pinpoint the severity and cause of the fatigue.

In bringing a long-term disability case, an attorney experienced in litigating claims under the Employee Retirement Income Security Act of 1974 (ERISA) will always challenge the insurance company’s “experts”, and create a proper record of not only the symptoms of the underlying conditions, but also the side effects of the medication prescribed for treatment of the conditions.

Alan Olson writes this web-log to provide helpful information regarding long-term disability cases. He practices long-term disability law throughout the United States from his offices in New Berlin, Wisconsin. Attorney Olson may be contacted at [email protected] with questions about the information posted here or for advice on specific disability benefit claims.


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