Mark D. DeBofsky is a name partner of DeBofsky Sherman Casciari Reynolds P.C. — on the web at debofsky.com. He handles civil and appellate litigation involving employee benefits, disability insurance and other insurance claims and coverage issues. He can be reached at [email protected]
What is “objective” evidence? A recent ruling from the 6th U.S. Circuit Court of Appeals definitively answered that question.
The case of Outward v. Eaton Corp. Disability Plan for U.S. Employees, 2020 WL 1514852 (6th Cir., March 30) (unpublished), involved a claim for long-term disability insurance benefits from Teresa Outward, a long-time employee of Eaton Corp. Outward’s career came to a halt, though, in 2011, after she began experiencing a cascade of severe medical problems and had to cease working.
Soon after, Outward applied for and was approved to receive disability benefits from Eaton’s self-funded long-term disability plan, but only for 24 months. Benefits ended because the continuation of benefits beyond 24 months required Outward to prove she was unable to engage in any occupation on either a full-time or part-time basis; Eaton determined she was unable to make such a showing. Although Outward was unsuccessful in the district court, she won her case in the court of appeals.
Much of the opinion is focused on the issue of whether Eaton’s acknowledgement that Outward was unable to work on a full-time basis was sufficient to qualify her for ongoing benefits. The court held the issue had been decided by McClain v. Eaton Corp., 740 F.3d 1059 (6th Cir. 2014). There, the 6th Circuit ruled the plan’s requirement of being “totally and continuously unable to engage in any occupation or perform any work for compensation or profit” allowed the plan to deny benefits to any claimant who could work at all, even if limited to part time work.
Although Outward failed to convince the court to revisit that ruling, she did succeed in arguing the evidence she submitted was sufficient to prove her complete inability to work. The issue turned on the plan’s requirement that disability claimants submit “objective” evidence.
The court observed: “Eaton’s plan does require a claimant to provide objective findings of a disability. Although the plan provides that ‘objective findings’ do not include a claimant’s description of her own symptoms, they do include — in addition to X-ray and diagnostic test results — findings from physical exams, diagnoses, observation of abnormalities, medications and treatment plans. Outward presented voluminous evidence of her restrictions through the diagnoses from her treating physician, through the findings from physical exams, through doctors’ observations of her diminished capacities and through the medications and treatment plans prescribed for her. Of course, in order to make those diagnoses and prescribe medications and treatment plans, physicians had to rely in part upon the patient’s own description of her condition, but such information is essential to providing proper medical care to any patient. Indeed, to ignore such proffered information would constitute medical malpractice.”
The court added that based on Corey v. Sedgwick Claims Management Services Inc., 858 F.3d 1024 (6th Cir. 2017), “reliance on test results only is no more predictive of an ability to perform certain work than is reliance on diagnoses, prescriptions, treatment plans, and other medical evidence.” Based on that precedent, the court found that Outward provided sufficient proof to establish her entitlement to benefits and questioned the contrary evidence from the plan’s consultant physicians since they had not examined the plaintiff.
The court was troubled that Eaton ignored the plaintiff’s allegations altogether, and explained: “The Plan Administrator’s reliance on the medical opinions of doctors who fell into the trap of relying only upon cherry-picked evidence provides additional support for our conclusion that the decision denying long-term disability benefits was arbitrary and capricious.”
The court further expounded: “[B]lind reliance on the results of certain medical tests often skews the true picture of an individual’s condition and ability to perform jobs within the economy. Here, although the tests upon which certain reviewers relied did not produce the results that they would have liked to see, other objective diagnoses and treatments showed that any expectation that Outward could perform any job without limitation or restriction was unprincipled, unreasoned, and contrary to the evidence in the record.
The court thus rejected Eaton’s argument that its physicians offered “reasoned” explanations for their opinions which maintained that negative findings on certain tests contradicted Outward’s claim.
The court disagreed with Eaton’s fundamental assertion that the absence of positive test findings supported the consulting doctors’ opinions and thus determined: “By concluding that Outward was not entitled to continued long-term disability benefits, the Plan Administrator gave great weight to the opinions of medical professionals who relied only on such tests and who could provide only a snapshot of Outward’s condition at certain points in time. In doing so, he necessarily discounted evidence offered by Outward’s treating physician and other professionals that provided a broader, more holistic, more complete picture of Outward’s situation. In short, the Plan Administrator, operating under an inherent conflict of interest, failed to consider all relevant evidence of Outward’s condition and her functional capacity. Such a failure thus calls into question the validity of the administrative decision, even under the deferential arbitrary-and-capricious standard of review.”
This ruling’s conclusion that objective test findings are often no more than a “snapshot” that does not necessarily correlate to a disability is a refreshing reminder that the search for objective evidence cannot end with test results and must encompass clinical findings as well. It defies logic to believe that someone would see doctors for years on end, take a variety of pharmaceuticals with mild-altering and other side effects and even undergo serious medical procedures just to fake a disability claim.
A well-developed record of treatment over a lengthy period such as the one Outward presented should suffice to establish proof of disability to even the most hard-nosed evaluator. If anything, the concern here, which the court impliedly recognized, should be about biased claim administrators who utilize over-restrictive criteria to deny meritorious claims.
This article was originally published in Chicago Daily Law Bulletin, April 30, 2020