Opinion ID: 152240
Heading Depth: 3
Heading Rank: 2

Heading: Functional Capacity Evaluations (FCEs)

Text: Subjectively painful conditions like CRPS and fibromyalgia pose difficult problems for private disability insurance plan administrators and the Social Security Administration, who understandably seek to make decisions based on the most objective evidence available. But we have rejected as arbitrary an administrator's requirement that a claimant prove her condition with objective data where no definitive objective test exists for the condition or its severity. See Hawkins v. First Union Corporation Long-Term Disability Plan, 326 F.3d 914, 918-19 (7th Cir.2003) (reversing denial of benefits where administrator determined that there were no objective findings to support restrictions, and noting that pain often cannot be detected by laboratory tests and that the amount of pain and fatigue that a particular case produces cannot be tested objectively); Diaz v. Prudential Ins. Co. of America, 499 F.3d 640, 646 (7th Cir.2007) (claimant's pursuit of extensive treatment including heavy medication and repeated surgical procedures supports an inference that his pain, though hard to explain by reference to physical symptoms, was disabling). At the same time, even in these difficult cases involving conditions where subjective symptoms of pain are not manifest in objective clinical data, we have allowed a plan administrator to require a certain degree of objectivity in terms of the measurement of physical limitations as observed in a functional capacity evaluation. A distinction exists however, between the amount of fatigue or pain an individual experiences, which as Hawkins notes is entirely subjective, and how much an individual's degree of pain or fatigue limits his functional capabilities, which can be objectively measured. Williams v. Aetna Life Ins. Co., 509 F.3d 317, 322 (7th Cir.2007). The district court correctly identified this distinction and focused on it. However, the quantity and quality of the functional capacity and other data that Holmstrom provided to MetLife readily distinguish this case from Williams. [10] Like Holmstrom, the claimant Lee Williams suffered from a condition (chronic fatigue syndrome) that is diagnosed by subjective patient complaints. And like MetLife, the administrator in Williams (Aetna) rejected the claimant's functional capacity data as insufficient. Unlike the present case, however, the Williams record lacked any specific data reflecting Williams's functional impairment. Williams, 509 F.3d at 323. Williams never presented an actual FCE or any measurement of specific limitations. He offered only his treating physician's unexplained conclusions that he could perform only low-stress jobs and could not lift anything over ten pounds. Aetna gave this physician a functional capacity questionnaire asking for the results of very specific functional tests ( e.g., how long Williams was able to stand before needing to sit down), which were answered unknown or untested. No specific tests of physical ability or endurance were ever performed. In this case, Holmstrom provided a physician opinion similar to the one in Williams, but she also presented two FCEs, at least one of which (from 2007) provided exactly the kind of detailed and specific information that the Williams court found lacking. At oral argument, MetLife urged us to take a critical look at the FCEs under the Williams standard. We have examined them, and we find that the 2007 FCE provides objective support showing functional limitations amounting to total disability. [11] The 2007 FCE report included 20 different detailed tests. Six examined arm function, and seven examined hand function. Each result included specific weight and time data, and applied that data to the lowest possible occupational exertion category as determined by the Department of Labor. Holmstrom fell short of the requirements of sedentary work in the majority of these tests. The tests were repeated one day later, with all measured parameters recorded [at] a reduction of about 20%, which suggested consistency of effort and very poor endurance. Those results indicated that it was unlikely that Holmstrom would be able to sustain even her severely compromised level of function over consecutive workdays, as needed for full-time employment. Despite the thoroughness of this 2007 FCE, MetLife rejected it. MetLife was obliged to explain why it found the FCE unreliable. See Leger, 557 F.3d at 834-35 (finding administrator's decision arbitrary). MetLife offers several explanations, but they lack substance and reflect arbitrary action. In addressing the 2007 FCE, Dr. Manolakas opined (and MetLife adopted the conclusion) that it is unclear on what basis precisely the lack of performance is due to: physical incapacity or poor effort. He stated: The language suggests poor effort and endurance, but without the entire report or a repeat study this is not able to be determined for sure. In other words, according to Dr. Manolakas, who was only reviewing the report, there was no way to tell whether Holmstrom was faking her poor function. The professionals who conduct FCEs for the purposes of occupational assessment are aware of this common concern, and they look for disability exaggeration. The 2007 FCE report makes no observation of any kind that might call Holmstrom's effort into doubt. MetLife ignores the consistency of the FCE, with nearly identical reductions in measured performance on the second day across all measured parameters. Nothing in this FCE or those from 2000 and 2005 calls Holmstrom's effort into question. [12] MetLife also challenges the validity of the 2007 FCE procedures, arguing that a valid FCE must include raw data and algorithms for scoring functionality. MetLife Br. 30. MetLife further cites sources that purport to explain how an FCE should be done. However, the cited sources in MetLife's brief are consistent with the methodology used in the 2007 FCE, and at oral argument MetLife counsel was unable to explain how a valid FCE would differ from this one. We look then to the 2000 FCE, which MetLife found satisfactory, and we see no material differencescertainly nothing in the way of raw data or algorithms with the exception of range of motion data, which Dr. Vant had provided to Dr. Manolakas' satisfaction in a separate letter prior to MetLife's 2007 decision confirming the termination of benefits. When questioned at oral argument about the perceived differences in the 2000 and 2007 FCEs, MetLife's counsel answered that the 2000 FCE contained five things that the 2007 one did not: range of motion data, strength tests, reflex tests, sensory tests, and detailed pain descriptions. Again, Dr. Vant provided range of motion data to MetLife's physician's satisfaction. The 2007 FCE contained 10 strength tests (the 2000 FCE also contained 10) that show no discernable difference in character or detail from the strength tests of 2000. While the 2007 FCE had no reflex tests, the 2000 FCE explicitly indicated that Holmstrom's right elbow reflex was not tested. The 2007 FCE lacked sensory testing, but her sensory testing results in the 2000 FCE were normal. Finally, there is no appreciable difference in the level of detail between the 2000 and 2007 pain descriptions. There is no reason to think that an FCE performed in 2007 under the same standards as the 2000 FCE would have produced a conclusion any different from the one that Holmstrom submitted for her final appeal. Furthermore, MetLife never communicated to Holmstrom that it would require an FCE of the same format and level of detail as the one from 2000. At oral argument, MetLife's counsel conceded that MetLife never communicated to Holmstrom these specific criteria for an FCE that it later demanded. MetLife has therefore failed to explain its rejection of the conclusions of the 2007 FCE, and there is an `absence of reasoning in the record' to support [MetLife's] conclusion that the 2007 FCE does not establish disability. See Leger, 557 F.3d at 835, quoting Tate, 545 F.3d at 559.