Court Affirms That Plaintiff Faces Medical Condition Not Addiction

Court affirms that plaintiff faces medical condition, not addiction

October 24, 2012
By Mark D. DeBofsky

Mark D. DeBofsky is a name partner of Daley, DeBofsky & Bryant. He handles civil and appellate litigation involving employee benefits, disability insurance and other insurance claims and coverage .

Abuse of prescription narcotic pain medications has drawn increasing media scrutiny now that drug overdose deaths have surpassed automobile accidents as the leading cause of accidental death in the United States (See, "Prescription for Addition," Wall Street Journal, Oct. 6, 2012). In a recent decision from Oregon, the court was called upon to decide whether an employee of Louisiana-Pacific Corp. was disabled due to an incurable medical condition or was simply addicted to OxyContin, a narcotic painkiller.

In Rabbat v. Standard Ins.Co., 2012 U.S.Dist.LEXIS 142336 (D.Ore. October 1, 2012), the court determined that Richard Rabbat, who worked as a computer help desk technician, was disabled due to Familial Mediterranean Fever (FMF), an incurable disorder that causes joint swelling resulting in severe pain. The factors that guided the court to reject the insurer's contention Rabbat was abusing drugs are described in the thorough opinion authored by U.S. District Judge Michael H. Simon.

The opinion recounted that Rabbat, who was approximately 46 years old, had suffered from Familial Mediterranean Fever since the age of 13 and had been deemed disabled by the Social Security Administration before he began working at Louisiana-Pacific. However, FMF is an episodic condition and Rabbat's physicians were able to bring his symptoms under sufficient control to allow him to begin working for that organization in May 2005. Rabbat's supervisor described him as "good at his job" and possessing "a strong work ethic"; however, periodic flare-ups caused Rabbat to miss work on an increasingly frequent basis.

The plaintiff finally had to cease working altogether in October 2008 and he was approved to receive short-term disability benefits for the next six months. However, after the expiration of the short-term benefits, Standard Insurance Co. denied Rabbat's claim for long-term disability payments following a file review performed by Dr. Bradley Fancher who maintained that Rabbat was abusing opioids and was not receiving treatment for FMF. Another file review performed by Dr. Ronald Fraback reached the same conclusion and suggested that since Rabbat had been able to work for several years there was no identifiable reason why he could not continue to do so.

The plaintiff submitted substantial evidence, however, showing he was experiencing marked swelling of his joints and severe pain due to the swelling. Social Security disability benefits were also reinstated in 2009. Nonetheless, another file review performed by Dr. Ibrahim Alghafeer reached a conclusion that the "submitted data does not preclude Mr. Rabbat from performing sedentary level work ... " Thus, the benefit denial was upheld and litigation ensued.

Upon review and consideration of the parties' submissions, the court overturned Standard's denial, finding persuasive the evidence from the treating physicians. The fact that two doctors who had personally examined and treated Rabbat deemed him disabled due to FMF was sufficient to convince the court. The court also relied heavily on Salomaa v. Honda Long Term Disability Plan, 642 F.3d 666, 676-79 (9th Cir. 2011), where the court ruled that opinions from examining doctors are often more probative than opinions from non-examining doctors who lack the knowledge that can only be gained from performing an examination.

The court also pointed to the consistency between the treating physicians' opinions and Rabbat's medical history, his record of increasing absences and the statement from the plaintiff's supervisor at work. Although the court expressed concern about Rabbat's heavy opioid usage, one of the treating doctors explained the narcotic dependence "results from his debilitating FMF and would not have occurred were it not for his underlying severe condition." Id.

The court also found that "narcotic dependency and chronic pain are not mutually exclusive conditions" and even though Rabbat had been referred for addiction counseling, his doctors steadfastly confirmed the disability.

Standard also argued that nothing in Rabbat's condition changed that would justify an onset of disability in October 2008. However, the court pointed to medical records that documented a gradual worsening in Rabbat's condition during that year and Rabbat's supervisor also noted his observations of the plaintiff's decline. The court also relied heavily on the observations made in Hawkins v. First Union Corp. Long-Term Disability Plan. 326 F.3d 914, 918 (7th Cir. 2003):

"A desperate person might force himself to work despite an illness that everyone agreed was totally disabling. ... Yet even a desperate person might not be able to maintain the necessary level of effort indefinitely. [The claimant] may have forced himself to continue in his job for years despite severe pain and fatigue and finally have found it too much and given it up even though his condition had not worsened. A disabled person should not be punished for heroic efforts to work by being held to have forfeited his entitlement to disability benefits should he stop working."

Thus, the court held that Rabbat's claim was supported and that benefits were due.

This ruling makes a number of key points instructive both to claimants and insurers. In addition to the significance of a consistent longitudinal record of treatment, the importance of medical examinations in cases that are heavily dependent on credibility determinations cannot be overemphasized. Courts are growing increasingly skeptical of physician file reviews in such cases.

Obviously, there first has to be an accepted relationship between the condition in question and the claimed debilitating symptoms. But even symptoms such as pain, which are incapable of being measured, can be corroborated as they were in this case by observations of joint swelling, redness and tenderness. And as in the Salomaa case cited by the court, evidence that the claimant had a good work record and was a well-regarded employee can be critical.

Finally, while many individuals with chronic illnesses are able to work, Hawkins recognizes it may be inevitable that many such individuals ultimately succumb to their maladies. The documentation here described Rabbat's increasingly tenuous ability to work, which also obviously convinced the court that this was not a case of drug addiction, but that the plaintiff was legitimately disabled by a severe incurable ailment.