Opinion ID: 618491
Heading Depth: 2
Heading Rank: 2

Heading: Disabling Effects of Pain and Other Symptoms

Text: I reach a different conclusion with respect to the impact of the symptoms of Maher's maladies -- chronic pain, nausea, vomiting, and food intolerance -- on her ability to work. After -35- careful review of the record, I find persuasive evidence that Maher's symptoms would prevent her from performing the duties of the jobs identified by Liberty. Before evaluating the record on this issue, I note that my concern here lies with the evidence of limitations attributable to Maher's symptoms, and not with whether the evidence supports Maher's underlying medical conditions. There is considerable uncertainty regarding the etiology of Maher's abdominal pain and other complaints, and attempting to resolve a question that has stymied multiple doctors for the past decade is both unnecessary and beyond my expertise.15 The diagnosis makes little difference here. Our court has emphasized before that in dealing with hardto-diagnose, pain-related conditions, it is not reasonable to expect or require objective evidence supporting the beneficiary's claimed diagnosis. See Cook v. Liberty Life Assurance Co., 320 F.3d 11, 21 (1st Cir. 2003). Our focus instead must be on whether evidence supports an inability to work due to the physical limitations imposed by the symptoms of such illnesses . . . . Boardman v. Prudential Ins. Co. of Am., 337 F.3d 9, 16 n.5 (1st Cir. 2003). 15 Dr. Goessling, a trained gastroenterologist and Associate Professor of Medicine at Harvard Medical School, continues to believe that Maher's abdominal symptoms are most likely caused by chronic pancreatitis. The Plan's doctors disagree, but concede that the record supports a diagnosis of either chronic pain syndrome with abdominal focus, per Dr. Malinoff, or fibromyalgia, per Dr. Millstein. -36-
I begin by assessing the evidence that, in the view of the Plan, calls Maher's limitations into question, the foremost of which is the alleged inconsistency between Maher's reported capabilities and the level of activity confirmed by surveillance. Liberty conducted surveillance of Maher on nineteen days between October 2002 and October 2006, portions of which were recorded on video.16 The Plan and its doctors highlighted a handful of examples of increased activity by Maher captured in the surveillance. On one occasion, Maher was observed walking to the front of her property carrying what appeared to be a flower / plant and a large bucket, and, four minutes later, walking back with the same bucket. On another, she drove herself a short distance (a fourminute drive) to a local school, where she went inside and returned carrying her son (then close to three years old), whom she placed inside the car before departing for her home. On a third occasion -- and the one on which the Plan places the most emphasis -- Maher's husband drove Maher and her son to a local soccer field on a Saturday morning. There, Maher was periodically observed as she and her husband flew a kite with the young boy, as she walked and jogged around the soccer field, and as she at one point lifted 16 This included six days of surveillance in 2002, three days in 2005, and ten days in 2006. -37- the small boy and swung him around in her arms. The outing lasted thirty-four minutes. This surveillance evidence does not have the significance that the Plan ascribes to it. In the activity questionnaires she submitted to Liberty, Maher consistently reported that the level of activity she can sustain is entirely dependent on her pain, nausea, and level of medication. For example, in her latest questionnaire, dated September 2006, Maher indicated that the amount of time she can tolerate sitting, standing, and riding in or driving a car depends on the presence of pain, nausea, vomiting, and diarrhea. She also noted that she leaves the house during the week two to three times a day (one to two times on weekend days), and that she helps take care of her children and perform small chores when she is able. As the majority points out, Liberty's surveillance is not inconsistent with Maher's own account of her activities. Over nineteen days of surveillance, there were a number of days in which Maher was confirmed to be at home and never left the residence. On other days, she left the house -- either as a passenger or driving herself -- to run a limited number of errands, mostly picking up or dropping off her children at school, and once to go to dinner at a restaurant. She was also observed outside on two brief occasions involved in what could generously be described as yard chores: carrying a flower pot and, on another occasion, sitting in the bed -38- of her husband's truck holding a broom or rake while her husband appeared to be cleaning up. All of this activity is consistent with her description of a low level of activity dependent on the ebb and flow of her symptoms. It would be unusual for a mother of three children to be able to avoid all activity. With regard to the kite-flying episode, which strays the farthest from Maher's reported limitations, Maher has indicated that the outing was a special event for which she premedicated with morphine. In other circumstances, this explanation might strain credulity. Here, however, the notion that Maher premedicates to prepare for activities that may trigger pain finds support in records that predate the incident.17 In a March 2003 activity questionnaire, for example, Maher noted that she travels by plane only with pre-medication for pain and nausea from increased cabin pressure on abdomen. In her September 2006 questionnaire, Maher also noted that her ability to carry out various activities of daily life always depend[s] on how much pain medicine I use . . . to help myself. Moreover, the entire outing 17 The district court concluded that, assuming that Maher's outing with her family can be explained by premedication, it is a reasonable inference that she could also pre-medicate to perform a sedentary job. I cannot agree. Maher takes a large amount of narcotics daily to address her background pain. The fact that she can, on top of this background dosage, take additional pain medications to ward off pain during the occasional short episodes of increased activity does not suggest that it would be feasible for her to regularly take extra medication to make it through an eight-hour workday. -39- at the athletic fields was very brief, lasting just over half an hour. It would be unfair to read too much into one short episode of increased activity, given the consistency of the larger record of surveillance with Maher's reported capabilities. Turning to an evaluation of the medical opinions concerning Maher's limitations, my conclusion again diverges from that of the Plan and its doctors. Among Maher's treating doctors, there is thin support for her capacity to return to a sedentary job. The most direct evidence is found in a questionnaire, completed by Dr. Gale Haydock, indicating that Maher is OK to perform sedentary duties. However, Dr. Haydock treated Maher only once, in the winter of 2006, when Maher was admitted to the hospital for several days to treat a flare-up of abdominal pain, and thus Dr. Haydock had no opportunity to observe the course of Maher's symptoms over time. One could also, as the Plan has, read various statements by Maher's primary care physician (Dr. Cuevas) to support Maher's ability to perform sedentary work. Most notably, in a conversation with Dr. Malinoff, Dr. Cuevas stated her agreement with Dr. Malinoff's opinion that, from a purely internal medicine perspective, there is no identifiable physical exam or anatomic / laboratory abnormality that would prevent [Maher] from working at a very minimum at a sedentary level. This awkwardly precise statement is technically true and is, undoubtedly, an accurate -40- reflection of Dr. Cuevas's medical opinion.18 It is also transparently misleading. Maher's medical records make clear that no doctor has been able to identify a physical or anatomic abnormality that causes her symptoms. However, the absence of a diagnosed medical condition says nothing about the reliability of Maher's complaints or whether her reported symptoms prevent her from working. On those questions, Dr. Cuevas's opinion is unequivocal. In a letter dated March 2007, Dr. Cuevas wrote that Maher remains in significant disability, both from her chronic pain and from the side effects the pain medication cause, and that she is unable to reliably perform duties because her pain can become so severe so quickly. Lastly, the record also contains opinions from the three doctors retained by the Plan -- Dr. Millstein, Dr. Malinoff, and Dr. Dean Hashimoto, Chief of Occupational and Environmental Medicine at MGH -- concluding that the available evidence does not support Maher's claimed inability to work a sedentary job. I find the opinions rendered by these doctors unpersuasive. Each doctor relied to a significant degree on the surveillance records in evaluating Maher's capabilities, focusing on the episodes of activity detailed above and finding them inconsistent with Maher's 18 Following their conversation, Dr. Malinoff mailed a letter to Dr. Cuevas that recapitulated the substance of their conversation and asked that she sign to verify its accuracy. She did so and returned the letter to Dr. Malinoff. -41- claims. Dr. Malinoff and Dr. Hashimoto also interpreted Dr. Cuevas's statements as supportive of Maher's ability to return to work. For the reasons stated, I have reached contrary conclusions based on the same evidence. Additionally, Dr. Hashimoto observed that, even accepting the veracity of Maher's reported symptoms, there has been no attempt to evaluate through neuropsych testing, scans, or other available means the extent to which Maher's pain and use of narcotics affect her cognition and ability to function. This failing can be attributed, to some degree, to the Plan's decision not to pursue an independent medical evaluation of Maher to assist in the assessment of her claim.19 Nevertheless, as I discuss below, I find the record evidence of Maher's limitations sufficient even absent the sort of testing suggested by Dr. Hashimoto. 19 Indeed, I find the Plan's failure to conduct an independent medical examination somewhat troubling. There is no requirement that a plan administrator arrange for a medical examination prior to terminating benefits, see Orndorf, 404 F.3d at 526, but here the circumstances certainly should have suggested its utility. As early as 2004, Dr. Millstein counseled that [i]f it is felt to be important to ascertain whether impairment due to abdominal pain exists, I would suggest consideration of functional assessment by some alternative means. After her benefits had been denied, Maher even offered to make herself available for a physical examination by a doctor of the Plan's choice. The record reflects that the Plan's administrators internally discussed the possibility of an independent medical examination in September 2007, but declined to pursue one due, in part, to concern for slowing down the process. -42-
Viewing the totality of the medical evidence in the administrative record, I am persuaded that Maher's symptoms prevent her from reliably performing the duties of a sedentary nursing job. At the fore of that evidence are the opinions of Maher's treating doctors, Dr. Cuevas and Dr. Goessling. As noted, Dr. Cuevas's assessment as of March 2007 was that Maher remains in significant disability and is unable to reliably perform duties because her pain can become so severe so quickly. Similarly, Dr. Goessling, who has followed Maher since the onset of her abdominal symptoms in late 2001, opined in a 2007 letter: In her current status, Mrs. Maher is barely able to provide for herself and her 3-year-old son during the day. She is not able to stand or walk for prolonged periods of time. She is suffering from constant nausea that is only partially relieved by her . . . medication. She has intermittent diarrhea due to malabsorption from lack of pancreatic enzymes followed by constipation caused by her high doses of narcotics medication. On top of her chronic abdominal pain, she has frequent exacerbations, [and] often this pain prohibit[s] her completely from taking any solid foods. . . . [¶] . . . [L]et me assure that I do not see any way that my patient would be able to sit or stand for prolonged period[s] of time let alone do physically or intellectually demanding work. While there is some evidence that Dr. Goessling did not actively treat Maher in 2006 and 2007, he saw her repeatedly in the -43- preceding years and she appears to have consulted with him prior to his writing the letter quoted above.20 These opinions echo Maher's own assessment of her limitations. In an affidavit, Maher stated that she cannot be counted on to do anything, because her symptoms come on unpredictably and leave her in excruciating pain that is so bad that it sucks the wind out of [her]. Though pain is subjective and thus difficult to reliably document, her characterization appears to be borne out by the record. From late 2001, she has consistently complained of intermittent and severe abdominal pain. Her complaints have been credible enough to convince the numerous doctors who have seen her that she needs serious narcotics to relieve her pain and allow her to function. While we might suspect drug-seeking tendencies in such circumstances, the record does not reveal such tendencies. An early note from Dr. Goessling indicates that Maher was quite reluctant to take pain medications, and there are multiple indications in later records of her desire to move off of the painkillers.21 Even with her regular regimen of 20 The letter, addressed to Maher's case manager at Liberty, begins, I would like to update you on [Maher's] overall condition, especially in light of the recent denial letter for her benefits that she received, implicitly suggesting that Dr. Goessling had current knowledge of Maher's condition at the time of writing. 21 Still, the record is mixed as to the sincerity of Maher's desire to discontinue narcotic use, as she has twice started treatment with a pain clinic and then failed to follow up. She ascribes her reluctance to continue treatment at the clinics to interpersonal conflict with the doctors at one clinic, and a -44- heavy narcotics, Maher's abdominal pain has repeatedly brought her to the emergency room, where she was admitted on at least two occasions for multiple-day stays to manage her pain. Maher's record of treatment thus bespeaks significant and debilitating pain. Given the number of medical professionals who have examined her and found her distress genuine, I have no reason to question the reality of this pain. As the Seventh Circuit noted in Carradine v. Barnhart, 360 F.3d 751 (7th Cir. 2004): What is significant is the improbability that [the claimant] would have undergone the pain-treatment procedures that she did, which included . . . heavy doses of strong drugs . . ., merely in order to strengthen the credibility of her complaints of pain and so increase her chances of obtaining disability benefits; likewise the improbability that she is a good enough actress to fool a host of doctors and emergency-room personnel into thinking she suffers extreme pain; and the (perhaps lesser) improbability that this host of medical workers would prescribe drugs and other treatment for her if they thought she were faking her symptoms. Such an inference would amount to an accusation that the medical workers who treated [the claimant] were behaving unprofessionally. Id. at 755 (internal citation omitted). I therefore credit Maher's reports of abdominal pain, and note as well that her gastrointestinal and food intolerance symptoms -- which are more readily verified -- find support in numerous records. feeling that the type of program offered by the other clinic was not appropriate for her. Her lack of follow-through in this regard does not diminish the overall force of the evidence of her pain. -45- I similarly find the evidence sufficient to corroborate Maher's claims that these symptoms would interfere with her ability to work. Maher's recurring acute attacks of abdominal pain would, at a minimum, result in frequent absences from work, which would be prohibitively disruptive of any attempt to maintain regular employment. Surveillance also suggests that her background level of symptoms is sufficient to keep her housebound with some frequency, or to permit only limited levels of activity. Though Maher may occasionally run errands, contribute to household chores, or even recreate with her family for short periods of time, there is a sharp difference between a person's being able to engage in sporadic physical activities and her being able to work eight hours a day five consecutive days of the week. Id. On balance, I conclude that the evidence demonstrates that Maher cannot reliably perform the duties of a full-time sedentary nursing job.