A sizable percentage of Employee Retirement Income Security Act cases involve disability benefit claims. Occasionally, a ruling comes along that provides valuable insight into the elements of what constitutes a winning case for a plaintiff seeking disability benefits.
On Jan. 3, the U.S. District Court for the Northern District of Texas decided Haynes v. Principal Life Insurance Co., which is a textbook example of such a case.[1]
The case involved a claim for disability benefits brought by Angela Haynes against Principal Life Insurance, which had issued a group long-term disability benefit insurance policy to her employer, an insurance agency. Haynes sought benefits when she became unable to continue working due to severe weakness, pain and fatigue.
Although Principal approved Haynes to receive short-term disability benefits, and then long-term disability benefits, it ceased paying benefits following a subsequent review of her claim. The court conducted a de novo review of the claim and overturned the denial.
The court described the medical evidence supporting the claim as “robust,” pointing to the testing and treatment Haynes had undergone from several doctors confirming a diagnosis of Ehlers-Danlos syndrome and which supported an inability to work due to pain, numbness and fatigue. Two of the treating doctors explicitly reported that Haynes could not perform any work on a full-time basis.
Although the court acknowledged that plan administrators are not obligated to give special weight to the opinions of a claimant’s physician,[2] the court found that “even when accorded only ordinary weight,” the treating doctors’ findings persuasively established that Haynes was unable to perform the requirements of her occupation. While Principal’s doctors disagreed, the court found those doctors’ findings were “less convincing” and “less persuasive” than the opinions rendered by Haynes’ doctors.
The court also rejected the findings made by one physician who had been retained by Principal to examine Haynes because the doctor’s conclusions were “inconsistent with the findings noted in his report.”
Another factor that influenced the court was the consistency of Haynes’ symptom reports. Although the court acknowledged Principal’s concern that the symptoms were self-reported, the court found “self-described pain cannot be disregarded merely because it is self reported.”[3] The court credited Haynes’ symptom reports because there was a consistent longitudinal record of worsening pain over the span of several years.
The court was also persuaded by a favorable Social Security disability determination made by an administrative law judge. The court determined that the Social Security finding was persuasive, even though it was not binding on the court, and was corroborative of the other evidence presented. The court also observed that the administrative law judge had found Haynes credible based on her lengthy work record and her reports as to the impact of her symptoms on her quality of life.
The court in this case addressed several issues that recur with frequency in cases involving disabilities based on subjective symptom reports and laid out a road map for resolving such ERISA-governed disability benefit cases. The key takeaways are as follows.
While the U.S. Supreme Court’s 2003 ruling in Black & Decker Disability Plan v. Nord[4] precludes courts from giving special consideration to treating doctors’ opinions, the Supreme Court also made it clear in that ruling that “[p]lan administrators, of course, may not arbitrarily refuse to credit a claimant’s reliable evidence, including the opinions of a treating physician.”[5]
Thus, the conclusion reached by the court in Haynes — that the treating doctors’ opinions were simply more persuasive than the competing evidence — carried significant weight with the court.
The Haynes opinion also discussed the consistency of the opinions presented by multiple physicians. When the claimant is seeing more than one doctor whose opinions are all supportive of the claimed disability, the plaintiff has a greater likelihood of achieving success in litigation.
The U.S. Court of Appeals for the Seventh Circuit’s 2007 ruling in Diaz v. Prudential Insurance Company of America is a corollary. In that case, the court recognized that a history of treatment with multiple doctors and “repeated attempts to seek treatment … supports an inference that [a claimant’s] pain, though hard to explain by reference to physical symptoms, was disabling.”[6]
Further, symptom complaints may not be automatically dismissed just because they are self-reported. Unless there is some evidence that would undermine a claimant’s reports of pain and fatigue, the insurance company has no basis for disregarding such complaints. In this instance, not only did Haynes express symptom complaints, but there was also corroborating evidence as to how those symptoms affected her quality of life.
Additionally, just because the insurance company has obtained an independent medical examination does not mean the insurance company ought to win. In this case, the examiner’s findings and his conclusion were inconsistent, which gave the court reason to discredit it.
Another important takeaway from the Haynes ruling is that a favorable Social Security determination is relevant evidence in support of a claim for disability insurance benefits. As the court in Haynes pointed out, while the Social Security determination was not dispositive, it constituted persuasive evidence since it offered further corroboration of the other evidence presented.
Further, a finding by an administrative law judge can be especially helpful in this type of case because the judge had the opportunity to observe the claimant’s demeanor and render a credibility determination. Since every federal appellate court but the Seventh Circuit treats ERISA denial-of-benefit cases as record review proceedings,[7] being able to present a Social Security administrative law judge’s credibility finding provides claimants with the opportunity to prove their credibility based on a written record.
Finally, the court in Haynes also noted the administrative law judge’s mention of the claimant’s lengthy work record. This is another key point supportive of disability.
The U.S. District Court for the Middle District of Tennessee’s 2021 ruling in Boersma v. Unum Life Insurance Company of America remarked on the same issue, noting that a disability benefit claimant’s “history of professional success and dedication to her career tends to weigh against any inference that she would falsify or exaggerate her symptoms to avoid her career responsibilities.”[8]
To be sure, disability insurers are faced with a difficult challenge when called upon to evaluate a claim where the disability is based on subjective symptoms. However, the lessons taught by the ruling in Haynes give both claimants and insurers a detailed, albeit hardly exhaustive, checklist to follow in validating or disproving such claims.
Mark DeBofsky is a shareholder at DeBofsky Law Ltd.
This article was first published by Law 360 on January 10, 2024.
[1] Haynes v. Principal Life Insurance, 2024 U.S. Dist. LEXIS 1698, 2024 WL 56990 (N.D. Texas January 3, 2024).
[2] Citing Black & Decker Disability Plan v. Nord, 538 U.S. 822 (2003).
[3] Citing Schexnayder v. CF Indus. Long Term Disability Plan, 553 F.Supp.2d 658, 667 (M.D. La. 2008).
[4] See, fn. 2.
[5] 538 U.S. at 834.
[6] Diaz v. Prudential Ins. Co. of Am., 499 F.3d 640, 646 (7th Cir. 2007).
[7] See, e.g., Orndorf v. Paul Revere Life Ins. Co., 404 F.3d 510 (1st Cir. 2005); But cf. Krolnik v. The Prudential Ins. Co. of America, 570 F.3d 841 (7th Cir. 2009).
[8] Boersma v. Unum Life Ins. Co. of Am., 546 F. Supp. 3d 703, 713 (M.D. Tenn. 2021)
