Deciding disability benefit claims correctly can often pose a challenge for both claimants and insurers. Since disability is dependent on functional restrictions and not just on a diagnosis, determining a claimant’s level of functionality with respect to basic activities such as sitting, standing and walking can be difficult, especially when disability results from symptoms such as pain.
A Jan. 29 ruling from the U.S. District Court for the Western District of Washington, in Dime v. Metropolitan Life Insurance Co.,[1] presents a thoughtful analysis of these issues, and offers valuable guidance both to claimants and insurers on how to evaluate medical opinions and determine a claimant’s disability when the medical evidence is uncertain as to the cause of disability.
The Dime ruling was decided in accordance with Rule 52 of the Federal Rules of Civil Procedure as a “trial on the papers” rather than on witness testimony in the courtroom. The court based its ruling on the evidence contained in the claim record assembled by MetLife.
The plaintiff, Heather Dime, who had worked as a wealth adviser, suffered from chronic abdominal and pelvic pain, although an exact cause for her symptoms could not be found. Despite undergoing a colonoscopy, hernia repair, an appendectomy, a hysterectomy and an ovarian cystectomy, Dime ultimately had to stop working on account of her intractable pain.
Dime’s ensuing claim for disability was denied, however, despite her treating doctor’s report that the pain was so severe and persistent that she could not work full-time even if she had the ability to alternate sitting or standing at will. A prelitigation appeal of the disability claim to MetLife was unsuccessful, and litigation followed.
The court found Dime proved her disability by a preponderance of the evidence. The court cited a bright-line rule set forth in 2016 by the U.S. Court of Appeals for the Ninth Circuit in Armani v. Northwestern Mutual Life Insurance Co., which found that the inability to sit for at least four hours a day precludes the performance of sedentary work that requires sitting for the majority of the day.[2]
The court pointed out that MetLife’s consultant had found Dime could only sit for up to four hours a day. But even without the Armani decision, the court concluded that Dime was unable to perform the material duties of her job given her need to lie down for an hour after 30 minutes of continuous sitting.
The court also rejected MetLife’s attacks on the credibility of Dime’s treating doctors, finding MetLife had misstated the length of the doctor-patient treatment relationship. The court thus accorded “significant weight” to the treating doctor’s opinions due to her “extensive relationship” with Dime.
The court was equally dismissive of MetLife’s unsupported claim that Dime herself supplied the contents of her treating doctor’s reports because separate reports described her condition using identical language. Citing the Ninth Circuit’s 2007 ruling in Orn v. Astrue, the court explained:
If anything, it is more likely that Dr. Li, as a qualified physician, witnessed Plaintiff repeatedly experiencing the same symptoms and felt that using the same language — rather than reinventing the wheel — would be the simplest way to keep record of it. After all, the primary function of medical records is to promote communication and recordkeeping for health care personnel, not to provide evidence for disability determinations.[3]
The court made the above point twice in the opinion due to its importance. Medical records rarely state the patient is disabled because that is not their purpose. Moreover, physicians are reluctant to “disable” their patients since their job is to enable them.
The court’s discussion also makes it clear that Dime was reluctant to pursue seeking disability benefits and tried other measures, including surgery, before she applied. The court thus correctly inferred that the events leading up to Dime’s disability application bolstered her credibility.
To that point, in 1999, the U.S. Court of Appeals for the Seventh Circuit, in Diaz v. Prudential Insurance Co. of America, explained that a disability claimant’s “repeated attempts to seek treatment for his condition supports an inference that his pain, though hard to explain by reference to physical symptoms, was disabling.”[4]
Another important consideration that was obviously on the court’s mind was Dime’s inability to concentrate and maintain attention at work while suffering from such severe pain that she needed to lie down. Several cases have recognized that an employee who is only able to work sporadically is unemployable,[5] and the same consideration would apply to an employee who would need to take excessive unscheduled breaks or be frequently absent from work.[6] Thus, the court appropriately found that Dime’s pain rendered her unable to meet her job requirements.
Although the source of Dime’s pain could not be definitively determined, her disability status could. Despite the advanced diagnostic tools available to doctors, an exact diagnosis as to the source of Dime’s pain remained elusive.[7] The major significance of the Dime ruling is that while the court could not point to explicit functional limitations that supported Dime’s disability application, it was able to draw inferences from the claimant’s treatment history, which it used to reject the defendant’s counter inferences.
The implications of the Dime ruling both for employees and disability insurers are clear. Employees who are unable to work should not be deterred from seeking disability benefits due to a lack of objective proof documenting their impairments.
Obviously, an impairment that is detectable on medical tests would not be established where such testing is lacking. Or, if the test findings are negative, it can be challenging for a claimant to prove their disability. However, where no testing is available, a consistent record of treatment, a solid work record and strong physician support may suffice to prove disability.
For insurers, the lesson learned from Dime is that they cannot simply slough off a claimed disability due to the absence of a precise diagnosis or objective test findings. Insurers must consider the entire record and the inferences raised by the evidence when making claim decisions with the understanding that medical records may not explicitly document disability since that is not the purpose of the records.
While the majority of disability claims involve musculoskeletal, cardiac, endocrine, or neurological conditions or disorders, cases such as Dime v. MetLife are not unusual. The road map drawn by the court in the Dime ruling can be a template for future cases.
The court’s analysis of a disability due to pain is also applicable to disabilities due to other symptoms, such as fatigue or dizziness. The ultimate decision comes down to the claimant’s credibility; and Dime’s discussion of factors that are indicia of credibility will undoubtedly guide and be relied on in future cases.
Mark DeBofsky is a shareholder at DeBofsky Law Ltd.
This article was first published by Law 360 on February 13, 2025.
[1] Dime v. Metropolitan Life Insurance Company, 2025 U.S. Dist. LEXIS 16059 (W.D. Wash. January 29, 2025).
[2] Armani v. Nw. Mut. Life Ins. Co., 840 F.3d 1159, 1163 (9th Cir. 2016).
[3] Citing Orn v. Astrue, 495 F.3d 625, 634 (9th Cir. 2007).
[4] Diaz v. Prudential Ins. Co. of Am., 499 F.3d 640, 646 (7th Cir. 1999).
[5] See, e.g., Rush v. McDonald’s Corp., 966 F.2d 1104, 1115 (7th Cir. 1992).
[6] Reinaas v. Saul, 953 F.3d 461, 464–65 (7th Cir. 2020).
[7] See Gaylor v. John Hancock, 112 F.3d 460, 467 (10th Cir. 1997) (“Medicine is, at best, an inexact science, and we should not disregard the great weight of the evidence merely because objective laboratory diagnostic findings either are not yet within the state of the art, or are inconclusive”).
