Source: https://www.burkeharvey.com/news-articles/court-rules-against-unum-in-case-of-fibromyalgia-disability-denial
Timestamp: 2019-04-23 04:44:58+00:00

Document:
“The essence of UNUM’s argument is that fibromyalgia is not an objectively diagnosable disease. The courts disagree. “Fibromyalgia is a type of muscular or soft-tissue rheumatism that affects principally muscles and their attachment to bones, but which is also commonly accompanied by fatigue, sleep disturbances, lack of concentration, changes in mood or thinking, anxiety and depression.” Lang v. Long-term Disability Plan of Sponsor Applied Remote Tech., Inc., 125 F.3d 794, 796 (9th Cir. 1997) (citing The Arthritis Foundation, Fibromyalgia, Arthritis Foundation Pamphlet at 1, 5 (1992)). Recognizing the ability to detect and diagnose the condition, several courts have awarded disability benefits under ERISA for fibromyalgia. See e.g., Lang, 125 F.3d at 799; Godfrey v. BellSouth Telecomm., Inc., 89 F.3d 755, 759-60 (11th Cir. 1996). The Godfrey court noted that “fibromyalgia can be severely disabling and can only be diagnosed by an examination of the patient.” Godfrey, 89 F.3d at 758. Hence, courts often affirm an administrator’s denial of benefits when that decision is supported by one or more independent medical examinations. See e.g., Robinson v. Phoenix Home Life Mut. Ins. Co., 7 F.Supp.2d 623, 632-33 (D. Md. 1998) (denying benefits to fibromyalgia claimant based on two separate medical opinions); Bremer v. Hartford Life & Accident Ins. Co., 16 F.Supp.2d 1057, 1061-62 (D. Minn. 1997) (same). Therefore, courts are aware that fibromyalgia is a diagnosable condition. More importantly, the medical community also recognizes this fact.
The opinion of the court was delivered by: Herlong, District Judge.
This ERISA*fn1 matter is before the court on the parties’ cross-motions for summary judgment. Elaine Russell (“Russell”) seeks to recover long-term disability (“LTD”) benefits under a group insurance policy (“the Plan”) issued by UNUM Life Insurance Company of America (“UNUM”). Russell suffers from several ailments and has been diagnosed with fibromyalgia. The Plan has a one-year limitation on payments for disabilities caused by “self-reported symptoms.” (Def.’s Cross-Mot.Summ.J. at 4.) Citing this limitation, UNUM offered to pay Russell one year’s worth of benefits. Russell seeks full LTD benefits. For the reasons set forth below, Russell is entitled to full LTD benefits.
UNUM continued to seek information from these physicians through January of 1999. Rather than wait any longer for UNUM’s decision, Russell filed the instant action on January 26, 1999. Russell submitted her motion for summary judgment on February 17, 1999. On March 4, 1999, UNUM filed its cross-motion for summary judgment.
In this ERISA case, the standard of review of the administrator’s decision is for “modified” abuse of discretion. Normally, “[i]n cases where the benefit plan grants the administrator or fiduciary discretionary authority to determine eligibility or to construe the terms of the plan, the denial decision must be reviewed for abuse of discretion.” Ellis v. Metropolitan Life Ins. Co., 126 F.3d 228, 232 (4th Cir. 1997) (citing, e.g., Firestone Tire and Rubber Co. v. Bruch, 489 U.S. 101, 111, 115, 109 S.Ct. 948, 103 L.Ed.2d 80 (1989)). This standard is deferential, and “the administrator[‘s] . . . decision will not be disturbed if it is reasonable.” Id. (citing, e.g., Bruch, 489 U.S. at 115, 109 S.Ct. 948). “Such a decision is reasonable if it is ‘the result of a deliberate, principled reasoning process and it is supported by substantial evidence.'” Id. (quoting Brogan v. Holland, 105 F.3d 158, 161 (4th Cir. 1997) (citation omitted)).
certain interpretation of benefit eligibility or other plan terms, the more objectively reasonable the administrator or fiduciary’s decision must be and the more substantial the evidence must be to support it.
contract with insurance companies to provide and administer health care benefits to employees through group insurance contracts.
Doe v. Group Hospitalization & Med. Servs., 3 F.3d 80, 86 (4th Cir. 1993). The Fourth Circuit implied that a “mechanism to collect from the employer retrospectively for unexpected liabilities” could remove the conflict. Id. In the instant case, however, the insurance policy between UNUM and Delta Woodside makes no mention of any such mechanism, and no other evidence has been presented to show such a mechanism. As a result, the court will apply the less deferential “modified” abuse of discretion standard.
there is additional evidence that the claimant could not have presented in the administrative process.
Quesinberry, 987 F.2d at 1027. No motion has been made for the court to consider additional evidence, and additional evidence is not necessary in order to dispose of the instant motion.
Russell is entitled to full LTD benefits. As detailed above, UNUM does not dispute that Russell is disabled. See (Def.’s Cross-Mot.Summ.J. at 13.) UNUM simply asserts that, under the Plan, Russell’s benefits are limited to one year because her disability is “based entirely on her own report of her symptoms to her physicians and is unsupported by any objective test results.” (Id.) UNUM has the authority and discretion to limit benefits for such a category; however, it must abide by the terms that it sets. UNUM abused its discretion in not following the terms and definitions set forth in the Plan.
tied to the fibromyalgia is clearly demonstrated by the MRI which was taken and the fibromyalgia is demonstrated [by] all of the objective evidence by which it can be demonstrated.
examinations to examine Russell; (2) recognized that fibromyalgia is diagnosed through the use of a standardly accepted “pressure point” test; and (3) applied Russell’s condition to the test to determine that she suffers from fibromyalgia. As a result, Russell’s condition does not fall under the “self-reported symptom” limitation.
The essence of UNUM’s argument is that fibromyalgia is not an objectively diagnosable disease. See (Def.’s Cross-Mot.Summ.J. at 10.) The courts disagree. “Fibromyalgia is a type of muscular or soft-tissue rheumatism that affects principally muscles and their attachment to bones, but which is also commonly accompanied by fatigue, sleep disturbances, lack of concentration, changes in mood or thinking, anxiety and depression.” Lang v. Long-Term Disability Plan of Sponsor Applied Remote Tech., Inc., 125 F.3d 794, 796 (9th Cir. 1997) (citing The Arthritis Foundation, Fibromyalgia, Arthritis Foundation Pamphlet at 1, 5 (1992)). Recognizing the ability to detect and diagnose the condition, several courts have awarded disability benefits under ERISA for fibromyalgia. See e.g., Lang, 125 F.3d at 799; Godfrey v. BellSouth Telecommunications, Inc. 89 F.3d 755, 759-60 (11th Cir. 1996). The Godfrey court noted that “fibromyalgia can be severely disabling and can only be diagnosed by an examination of the patient.” Godfrey, 89 F.3d at 758. Hence, courts often affirm an administrator’s denial of benefits when that decision is supported by one or more independent medical examinations. See e.g., Robinson v. Phoenix Home Life Mut. Ins. Co., 7 F. Supp.2d 623, 632-33 (D.Md. 1998) (denying benefits to fibromyalgia claimant based on two separate medical opinions); Bremer v. Hartford Life & Accident Ins. Co., 16 F. Supp.2d 1057, 1061-1062 (D.Minn. 1997) (same). Therefore, courts are aware that fibromyalgia is a diagnosable condition. More importantly, the medical community also recognizes this fact.
ORDERED that Russell’s motion for summary judgment is GRANTED.

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