Proving an entitlement to disability benefits on account of headaches can be extremely challenging.Unlike many other disabilities that can be objectively diagnosed by MRI, x-ray, or blood tests, “objective” proof of headaches can be elusive.The proof difficulties can be even more challenging if the benefit plan requires objective medical evidence.How then can a claimant establish disability on account of severe headaches?A recent appellate ruling Corey v. Sedgwick Claims Mgmt. Svcs., Inc., 858 F.3d 1024 (6th Cir. 2017), offers some helpful guidance and instruction.
The case involved Bruce Corey, who was employed by Eaton Corporation as a machine operator until he had to stop working in 2014 due to cluster headaches.Although Corey was initially approved to receive short-term disability benefits, his claim was terminated shortly thereafter due to the claimed absence of objective findings.The Eaton plan provides: “[o]bjective findings include … [m]edications and/or treatment plan.” Since Corey’s physicians prescribed medication and other therapy, and performed an occipital nerve block in an effort to treat the migraines, the court concluded that the treatment Corey received satisfied the objective proof requirement.
Sedgwick argued that the absence of objective findings precluded Corey from receiving benefits.However, Corey maintained the plan administrator failed to engage in a deliberate, principled reasoning process because it disregarded his medications and treatment plan, as well as detailed physician notes describing the cluster headaches Corey experienced. The court agreed with Corey.The court was troubled by the absence of any discussion by either the plan administrator or any of the consulting physicians as to whether the medications and treatment plan substantiated the presence of cluster headaches. The plan took the position that the diagnosis itself was irrelevant. Instead, the plan maintained that Corey was required to submit evidence that medication or treatment plan must “objectively confirm that the individual is unable to work.” The court disagreed, observing:
We agree with Corey that his medication and treatment history satisfy the plan’s objective-findings definition. Indeed, the plan is clear and unambiguous: “Objective findings include … [m]edications and/or treatment plan.” The Administrator’s additional requirement that the medication and treatment plan either cause the disability or confirm the applicant’s inability to work finds no support in the plan’s terms.
The court found the plan’s position that its objective evidence requirement necessitated proof of inability to work illogical, pointing out that “an x-ray showing nerve compression suffers from the same defect: it bespeaks the existence of a back condition, but doesn’t demonstrate whether the condition prevents the employee from working.”
The court acknowledged the broad interpretive discretion left to Eaton and Sedgwick set forth in the plan, but observed that the record “leaves us guessing” as to how the objective findings definition was interpreted – all the plan did was quote the language and then pronounce that Corey’s evidence was insufficient.However, as the court remarked, that does not suffice: “Although the Administrator enjoys interpretive latitude, we defer only to its actual interpretations–it can’t issue a conclusory denial and then rely on an attorney to craft a post-hoc explanation. See Univ. Hosps. of Cleveland v. Emerson Elec. Co., 202 F.3d 839, 848 n.7 (6th Cir. 2000).”
Eaton’s position was absurd – although headaches may not be detectable in an MRI scan, the doctor’s records and the medication and treatment administered clearly established Corey’s impairment. From the clinical findings alone, it was obvious that Corey was afflicted to such a degree that he was unable to work. Although a benefit plan has the right to insulate itself against having to pay a claim that is supported exclusively by self-reports without any clinical support or laboratory corroboration, Eaton tried to take that position to deny a meritorious claim and erect a proof requirement that would be impossible to meet. The Sixth Circuit Court of Appeals rightly called foul and overturned the denial.