If you or a loved one has fibromyalgia, you're probably familiar with how often it is misunderstood and misdiagnosed. Unfortunately, this misunderstanding can often lead to inadequate treatment and denial of disability insurance claims.
Aetna Life Insurance Company has attracted significant judicial scorn of late in the manner in which it adjudicates disability benefits.Two recent decisions are illustrative - Jalowiec v. Aetna Life Ins. Co., 2015 WL 9294269 (D. Minn. December 21, 2015) and Granville v. Aetna Life Ins. Co., 2015 WL 9026025 (M.D. Pa. December 15, 2015).In Jalowiec, which involved a disability insurance claimant who suffered from daily debilitating headaches, a benefit claimant was denied long-term disability insurance benefits despite certification of his disability by several treating doctors.The court criticized Aetna for its reliance on reviewing doctors who engaged in a selective consideration of the evidence and who never consulted with the treating doctors to seek clarification of their opinions.
Qualifying for disability benefits based on headaches or other disorders that are so painful that narcotic medications are prescribed can be a major challenge. Since there is no objective way to measure pain and because most migraine and cluster headaches are impossible to diagnose with objective testing such as MRI studies, disability insurers often resist paying benefit claims, especially if the benefit plan or policy requires the submission of "objective" medical evidence. But there are methods to improve the chances of having claims paid.
Disability is not always based on a single medical condition. Many individuals suffer from multiple impairments; and while no single condition may be disabling, the combined co-morbidity of disparate impairments justify an entitlement to disability benefits. That was the lesson taught by Curtis v. Hartford Life & Acc.Ins.Co. 2014 WL 4185233 (N.D.Ill. August 20, 2014) (attached) which involved Cindy Curtis, a former operating room nurse at Lurie Children's Memorial Hospital in Chicago, who became disabled in 2007 due to injuries to her back, knees and shoulders, resulting in arthritis, fibromyalgia and myofascial pain throughout her body. Although Curtis received two years of benefit payments after Hartford determined that she could not perform the material duties of her regular occupation, benefits were discontinued thereafter because the standard for continued payment required her to show an inability to perform the duties of any occupation she was capable of performing based on her education, training and experience and which paid a salary commensurate with her pre-disability earnings. The court overturned Hartford's determination.
In Criss v. Union Security Ins.Co., 2014 WL 2707774, 2014 U.S.Dist.LEXIS 79300 (N.D.Ala. June 11, 2014), Judge William Acker, Jr. challenged the current methodology utilized by courts in adjudicating benefit disputes brought under ERISA. The court based its premise on the universally recognized legal maxim, nemo judex in causa sua; i.e., "No man should be the judge in his own case." (citing Chief Justice Sir Edward Coke in Dr. Bonham's Case, 8 Co. Rep. 107a, 77 Eng. Rep. 638 (C.P. 1610)). In derogation of that principle, the court noted that "clearly conflicted ERISA plan administrators and insurers, when granted by the plan document that they drafted full discretion to interpret their plans and to decide the ultimate issue of entitlement, are routinely allowed, even required, to rule on their own cases."