Opinion ID: 2790080
Heading Depth: 3
Heading Rank: 2

Heading: Dutkewych's Disability

Text: In early 2008, Dutkewych suffered from mental illness, substance abuse, and a dizzying array of physical symptoms that have since received competing diagnoses. Dutkewych left his work as an associate attorney at a Boston law firm on October 3, 2008, and sought LTD benefits from Standard. We summarize here the relevant chronology of Dutkewych's medical history and Standard's decisions concerning his benefits.
In March 2008, Dutkewych began to experience symptoms including severe fatigue, intense back pain and stomach irritation. His symptoms worsened over the summer as Dutkewych developed a painful rash, began bruising and bleeding, suffered severe joint pain, and experienced cognitive issues, including trouble with reading comprehension, concentration, short term memory, directions, organization, and sense of time. His primary care physician, Dr. Eric Serrano, did not identify a cause. In August 2008, Dr. Serrano referred Dutkewych to a hematologist-oncologist, Dr. Brenda Haynes, who considered the possibility of Lyme disease. At that time, Dutkewych reported no recent viral exposure or tick exposure that he [was] aware of. A blood test returned negative results for Lyme disease, but the test results warned that false negatives are possible in the early -6- stages of the disease before the patient produces detectable levels of antibodies. Dr. Serrano then referred Dutkewych to a rheumatologist, Dr. Don Goldenberg, who examined Dutkewych in September 2008. Dr. Goldenberg concluded that Dutkewych's musculoskeletal symptoms are consistent with what is termed fibromyalgia, which overlaps significantly with mood and sleep disturbances. Dr. Goldenberg noted that Dutkewych had a history of obsessive compulsive disorder, which made it likely that unexplained physical symptoms with multiple physician evaluations would heighten the intensity of the symptoms. He recommended Dutkewych's treatment be primarily regulated by [his] psychiatrist. One week later, Dutkewych visited the psychiatric emergency department at the Cambridge Hospital. He reported his mental health history and his more recent somatic symptoms. He noted his recent diagnosis by Dr. Goldenberg, and attributed his worsening depression to the idea that his doctors did not want to pursue his physical symptoms. At that time, his wife reported that he was self-medicating with prescription drugs. Dutkewych was admitted to the Cambridge Hospital's Partial Hospitalization Program, an outpatient program, for the following two weeks. At discharge, he was diagnosed with major depressive disorder, obsessive compulsive disorder, and generalized anxiety disorder. -7- In November 2008, Dutkewych visited a family practitioner, Dr. Jeanne Hubbuch, who ordered additional tests for Lyme disease. This time, Dutkewych reported experiencing no tick bites, but noted that ticks had been seen in his house. Western blot test returned positive results for Lyme disease under the IGeneX IGG criteria, but negative results under CDC/NYS and Babesia FISH criteria. On December 9, 2008, Dutkewych was admitted to the McLean Hospital for substance abuse treatment. At the hospital, he reported that he had been abusing Vicodin, and explained that he had used a stolen credit card to buy things that he then sold to pay for drugs. His intake form noted his recent diagnosis of Lyme Disease and his ongoing depression. He was discharged from the hospital on December 15, 2008, and immediately entered McLean's residential treatment program. In an Ambulatory Services Initial Assessment, Dutkewych reported a [l]ongstanding history of obsessive compulsive disorder and episodic depression. Although his OCD was in reasonably good control, his depressive symptoms were still significant and included suicidal ideation. He admitted to persistent and daily substance abuse over the last year. Dr. Joshua Katz, who evaluated Dutkewych during this time, reported that [m]any if not all of [Dutkewych's] physical and cognitive symptoms can be explained by -8- chronic narcotic use and intermittent withdrawal symptoms. Dutkewych was discharged on January 21, 2009.
On April 16, 2009, Standard approved Dutkewych's claim for LTD benefits. At that time, a significant portion of the medical records in Mr. Dutkewych's claim file relate[d] to his psychiatric condition. The physician consultant who reviewed his records noted that Mr. Dutkewych has had a combination of chemical dependency and psychiatric disorder of life threatening proportions. Standard concluded that his claim supports that as of October 4, 2008, [Dutkewych] has been unable to perform with reasonable continuity the Material Duties of his Own Occupation due to symptoms and treatment related to substance abuse and major depression. Standard specifically warned Dutkewych that his policy limits payment of LTD benefits to 24 months during your entire lifetime for a Disability caused or contributed to by Mental Disorders, Substance Abuse or Other Limited Conditions. As major depression is considered to be a Mental Disorder, Standard will be applying the Mental Disorder limitation and thus limiting payment of LTD benefits to a maximum of 24 months. 3. Dutkewych's Treatment for Chronic Lyme Disease Between June 2009 and December 2009, Dutkewych entered a second residential substance abuse treatment program and -9- participated in two halfway house programs. From around June 5 to June 22, 2009, Dutkewych was admitted to the McLean Adult Partial Hospital and Residential Program. From June 22 to September 29, 2009, he resided at Phoenix House Springfield Center, a residential facility for substance abuse treatment in Springfield, Massachusetts. From September 29 to December 21, 2009, he continued his treatment at the North Cottage Program, a residential facility for substance abuse treatment in Norton, Massachusetts. During this time, Dutkewych began seeing Dr. Karen Isselbacher, Dr. Luz J. Ruiz, and Dr. Bernard Raxlen. Each agreed with the diagnosis of Lyme disease. Dr. Isselbacher, a primary care physician, conducted a spinal tap in July 2009, and found elevated levels of proteins which she interpreted as evidence of Lyme disease. Dr. Raxlen, a psychiatrist, diagnosed Dutkewych with Lyme disease in December 2009 following a SPECT scan and a clinical evaluation. Dr. Ruiz, a neurologist, sought an additional Western blot test in December 2010 which returned identical results to the test in November 2008 -- positive for Lyme disease under IGeneX criteria, but negative for Lyme disease under CDC/NYS criteria. Under their care, Dutkewych has intermittently received intravenous (IV) antibiotic treatment for Lyme disease. After consulting with three physicians, respectively at Columbia, John's Hopkins, and Beth Israel, Dr. Isselbacher began to treat Dutkewych -10- with IV antibiotics in July 2009. While on IV antibiotics from July 2009 to March 2010, Dutkewych reported improved symptoms. He suffered a relapse after ending treatment, and restarted IV antibiotics in April 2010. He stopped again in June 2010, when his port became infected, and restarted in February 2011, when a new port was installed. During this time frame, Dutkewych also applied for and received a premium waiver on his life insurance policy from Standard and total disability benefits from the Social Security Administration (SSA). On April 28, 2009, Standard approved Dutkewych for a premium waiver on his life insurance policy based on a disability. On June 10, 2010, the SSA approved Dutkewych for total disability benefits due to Lyme Disease, fibromyalgia, muscle/joint pain, depression and substance abuse. The SSA found that Dutkwewych's Lyme Disease with associated joint pain and fatigue as well as his depression preclude him from performing work at any exertional level of the occupational base on a 'regular and continuing basis.' 4. Standard's Termination of LTD Benefits On April 27, 2011, Standard informed Dutkewych that his benefits would be terminated as of June 1, 2011,1 due to the end of the 24-month Limitation Period. Standard explained that, 1 The 24-month period was extended by 60 days under the terms of the Plan. -11- [b]ecause the Group Policy limits payments for Disability caused or contributed to by a Mental Disorder, in order to continue to receive LTD Benefits, Mr. Dutkewych must be Disabled by a Physical Disease or Injury. Specifically, [t]he Physical Disease(s) or Injury(ies) must be so severe as to cause Disability in the absence of Substance Abuse, a Mental Disorder or Other Limited Condition. Standard relied on a physician consultant, Dr. Leonard Sigal, described as board-certified in internal medicine and rheumatology and a leading figure in both the treatment and research of chronic Lyme disease for many years,2 to review Dutkewych's entire medical record. Dr. Sigal concluded that Dutkewych's diagnosis of Lyme disease was speculative. He noted that Dutkewych's antecedent psychiatric disorder, substance abuse, and diagnosis of fibromyalgia had been overshadowed by his treating physicians in favor of the premise that all of his complaints [were] attributable to 'chronic Lyme disease.' In so concluding, Dr. Sigal discounted the positive Western blot results at the IGeneX laboratory since, in his experience, the laboratory routinely reports positive results that are not in agreement with clinical findings and . . . often reports positive results in patients with no likelihood of exposure. He 2 Dutkewych argues that Dr. Sigal's experience has been confined to the position that chronic Lyme disease does not exist and that individuals who are diagnosed with chronic Lyme disease more likely than not suffer from fibromyalgia or mental illness. -12- also disagreed with Dr. Isselbacher's reading of the spinal fluid analysis. He noted that spinal fluid obtained on July 17, 2009 had normal glucose, a trivially elevated protein, and no inflammatory white or red blood cells counted. He concluded that it was essentially normal. Dr. Sigal accordingly rejected the diagnosis of chronic Lyme disease by a small group of physicians, considered local or regional Lyme disease experts . . . despite the lack of explicit clinical and laboratory evidence and the lack of response to month after month of multiple antibiotic therapies . . . . In the termination letter, Standard stated that it could not conclude that a Physical Disease has been identified as defined by the policy. Furthermore, [e]ven if [it was] to accept the diagnosis of Lyme disease, the consulting physician noted that the claimant may be able to work at this time if his psychiatric issues were appropriately dealt with. Importantly, Standard explained that it was unable to conclude that Mr. Dutkewych remains Disabled as the result of a Physical Disease or Injury and since LTD Benefits payable for Disability caused or contributed to by Substance Abuse, a Mental Disorder or Other Limited Conditions are limited to 24 months, his claim will close with [Standard's] payment through June 1, 2011. Standard explained that Dutkewych could request a review of Standard's decision within 180 days. With his request for -13- review, Dutkewych would have the right to submit additional information in support of his claim. 5. Dutkewych's Request for Review On October 20, 2011, Dutkewych administratively appealed Standard's decision to limit his benefits to two years. He attached letters from his wife, his in-laws, two of his brothers, and two of his treating physicians. Each of his family members explained Dutkewych's struggles with Lyme disease over the past few years. His motherin-law stated that Mark's limitations are both physical and intellectual. She wrote that his depression is clearly a reaction to his pain and fatigue rather than an endogenous depression. His brother attested that Dutkewych had gone thr[ough] significant physical and mental changes over the past 2 years. As an example, his father-in-law related that Mark cannot read a simple novel without getting confused and . . . need[ing] to re-read the pages that he just read five minutes earlier. Dr. Sheila Statlender, a clinical psychologist who had been treating Dutkewych since March 2010, submitted a report dated March 28, 2011. Dr. Statlender stated that Dutkewych has not abused substances since they began treatment. Significantly, she diagnosed him with Mood Disorder Due to Neuroborreliosis (central nervous system Lyme disease), with Depressive Features and noted his ongoing symptoms of anxiety and depression. -14- Similarly, Dr. Ruiz's letter, dated August 21, 2011, found Dutkewych to have mental disorders, and attributed them to his diagnosis of Lyme disease. Amongst Dutkewych's persistent symptoms, Dr. Ruiz listed cognitive limitations, depression, and anxiety. But, Dr. Ruiz wrote that [d]epression and anxiety cannot explain Mr. Dutkewych's joint and muscle pain, headaches, neuropathy, lack of endurance and worsening fatigue upon exercise. These symptoms, and Mr. Dutkewych's clinical presentation, are consistent with Lyme disease. Dutkewych sent Standard an additional report from a neuropsychologist, Dr. Leo Shea, following evaluations on May 21, 2011, and June 4, 2011. Dr. Shea concluded that Dutkewych's significant decline in cognitive capacities cannot be explained by depression alone. He concluded that the cause of Mr. Dutkewych's cognitive difficulties is primarily based in the resultant neurologic sequelae of Lyme disease with central nervous system involvement. Dr. Shea noted that Dutkewych's cognitive reserve has also been impacted by his history of serial concussions, . . . obsessive compulsive diagnosis, and the medications prescribed to attenuate these diagnosed conditions. In addition, Standard had received a letter from Dutkewych, dated April 27, 2011, that summarized his own medical condition. Since first contracting Lyme Disease, Dutkewych wrote, my symptoms have clustered in four primary areas: extreme -15- fatigue and lethargy, intense joint pain, cognitive issues and depression/anxiety. To date all of these issues persist. Of all of the symptom areas, Dutkewych identified the cognitive issues as often the most troubling. Although he used to handle complex public bond financing at the law firm, he wrote that he was now forgetful, easily overwhelmed, and struggled with reading comprehension. Finally, despite working with my therapist weekly and taking anti-depressant medication, depression and anxiety continue to be an issue. Dutkewych noted that [i]t is consistent with Lyme Disease to have mental health issues that are rooted in the illness. 6. Standard's Denial After Administrative Review Based on Dutkewych's request, Standard's Administrative Review Unit reviewed Standard's decision to terminate Dutkewych's LTD benefits after 24 months. As part of this process, the Administrative Review Unit asked two independent physicians, who had not been involved in the earlier decision, to review Dutkewych's medical file. Specifically, the Administrative Review Unit asked Dr. Raymond Dattwyler,3 an immunologist and rheumatologist, to comment on the laboratory findings in Dutkewych's medical file, the CDC criteria, and the assessment of 3 Dutkewych notes that, [l]ike Dr. Sigal, Dr. Dattwyler has a long history with Lyme disease, as a member of the [Infection Disease Society of America] and an outspoken voice against the existence of chronic Lyme. -16- Dutkewych's condition. The Administrative Review Unit also asked Dr. Bob Gant, a clinical neuropsychologist, to review the information related to Dutkewych's claimed cognitive deficits, and the findings of Dr. Shea. In a report dated March 12, 2012, Dr. Dattwyler concluded that Dutkewych simply did not have the clinical manifestations that I would expect to see in a patient with Lyme disease. Critically to Dr. Dattwyler, Dutkewych's Lyme serologies are negative and none meet the CDC criteria. Dr. Dattwyler specifically rejected any test results from a lab that does not adhere to CDC guidelines, such as the IGeneX tests. Simply stated his negative serologies and his clinical picture strongly support the finding that Mr. Dutkewych does not have Lyme disease now and never did. In a report dated April 5, 2012, Dr. Gant stated that he was unable to establish a psychological or neuropsychological diagnosis with the available information. In my opinion, Dr. Gant wrote in an addendum report issued on April 20, Dr. Shea administered an insufficiently brief examination to support his conclusions regarding a diagnosis of Chronic Lyme Disease, workrelated limitations related to this disease, and his ultimate conclusions regarding impaired work functioning. Dr. Gant -17- recommended a comprehensive and forensically sophisticated neuropsychological examination to verify a definitive diagnosis.4 Both consulting physicians questioned the existence of chronic Lyme disease as a diagnosis in general. In his report, Dr. Dattwyler cautioned that there is no acceptable definition of 'chronic Lyme disease,' and that [i]t is not accepted as a diagnosis by mainstream medicine. Instead, [t]he term 'chronic Lyme disease' is being applied to patients with vague complaints most of who[m] have never had Lyme disease. Dr. Gant concur[red] with Dr. Dattwyler's statement that chronic Lyme disease is not accepted by mainstream medicine. In fact, Dr. Gant wrote in his report, available medical information indicates that there is not medical consensus that Lyme disease is a credible diagnosis to offer an individual with this claimant's clinical history. On May 4, 2012, the Administrative Review Unit issued a letter to Dutkewych's counsel to inform her that it had completed 4 In the review letter, the Administrative Review Unit noted that it had contacted Dutkewych's counsel and offered to arrange for a neuropyschological examination at The Standard's expense after receiving Dr. Gant's assessment. The Administrative Review Unit and Dutkewych's counsel had discussed that the results would not likely change the prior determination because The Standard did not find that a diagnosis of Lyme disease was supported in Mr. Dutkewych's case and because all of the other possible causes of impairment that were suggested by Dr. Gant related to psychiatric disorders or the treatment [Dutkewych] received for his psychiatric disorders. Given the above, Dutkewych's counsel declined to pursue the evaluation. -18- its independent review. The Administrative Review Unit found that the correct decision was to close [Dutkewych's] claim as [of] June 1, 2011 under the Disabilities Subject to Limited Pay Periods Provision of his Plan. In the review letter, the Administrative Review Unit reiterated that the Disabilities Subject to Limited Pay Periods provision of the [Plan] limits payment of LTD Benefits to 24 months during your entire life time for a Disability caused or contributed to by any one or more of the following . . . : 1) Mental Disorders, 2) Substance Abuse, or 3) Other Limited Conditions. The Administrative Review Unit then summarized, in detail, Dutkewych's medical history, the evidence that he had submitted in support of his claim that he was disabled as a result of Lyme disease, and the reports of Standard's consulting physicians. In addition, the Administrative Review Unit noted the controversy within the medical community regarding the diagnosis and treatment of Lyme disease. The Administrative Review Unit concluded that it is entirely reasonable and, in fact, prudent that The Standard evaluate disability claims in the context of mainstream medical opinion. Relying on the assessments of Drs. Dattwyler and Gant, and the consistent assessments of Drs. Sigal and Goldenberg, the Administrative Review Unit concluded that Dutkewych was not disabled as a result [of] Lyme disease. Rather, it stated, the available medical evidence supports that [Dutkewych]'s mental -19- health conditions in combination with his chronic pain condition (fibromyalgia) and substance abuse are the most likely cause of his reported symptoms. The Administrative Review Unit agreed with Standard's earlier decision to limit Dutkewych's benefits to 24 months under the Limited Conditions Provision as a result. The Administrative Review Unit explained: Because we do not find evidence to support that Mr. Dutkewych was impaired from performing his Own Occupation as of June 1, 2011 by a physical disease or injury (which was independent from his mental disorders, substance abuse and fibromyalgia with possible chronic fatigue), we have determined that Mr. Dutkewych does not qualify for additional LTD benefits from The Standard, and that his claim must remain closed.