California Court overturns Hartford’s denial of long term disability to plaintiff who suffers from chronic fatigue syndrome and awards benefits without remand.
Nagy v. Group Long Term Disability Plan for Employees of Oracle America, Inc. (Hartford) is helpful for plaintiff’s suffering from chronic fatigue syndrome (CFS) if the insurer continues to request objective evidence for the condition when, according to this California court, “There is no blood test or other objective laboratory test for chronic fatigue syndrome.” The Court recognized that this makes it difficult for plan administrators. Even so, relying on precedent, the Court noted “‘the lack of objective physical findings’ is insufficient to justify denial of disability benefits.” The Court concluded that, based on “the totality of the evidence,” Nagy qualified for long term disability benefits due his total disability and inability to perform the duties of any occupation.
Overview of the Case
After working as a software engineer, a sedentary position, for Oracle America, Inc., Nagy quit working and obtained short term disability benefits due to his CFS. He suffered from a number of symptoms associated with the condition, including over-sweating, excessive tearing, un-refreshing sleep, impairment in cognitive function, joint pain, sore throat, headaches and more. When his short-term benefits ended, his application for long term benefits was denied. He exhausted his administrative appeals and filed this ERISA lawsuit.
Nagy’s Treating Providers
Nagy was treated by several physicians in California who all agreed he was totally disabled from working in his own occupation. Their records were detailed and reported many visits where they observed Nagy and had no reason not to believe his reporting of his symptoms.
While Nagy was still struggling with Hartford to obtain benefits, he moved to Georgia and began treatment with a new physician. This doctor also agreed Nagy was disabled, although a few of his medical record notes indicated that Nagy was improving, his report to Hartford itemized Nagy’s symptoms and expressed his opinion that Nagy was disabled from working in his own occupation.
Hartford’s Four Independent Medical Reviewers
Hartford ordered four independent medical reviews of Nagy’s file, all board-certified in their own independent fields including: 1) An M.D. board-certified in Occupational Medicine and Aerospace Medicine; 2) An M.D. board-certified in in internal medicine; 3) An M.D. board-certified in Internal Medicine and Infectious Diseases; and, 4) A Ph.D., board-certified in Clinical Neuropsychology.
Not one of the reviewing physicians examined Nagy. They formed their opinions only on their review of the file. The reports consistently opined that Nagy was not disabled since there was no objective evidence in his file documenting a reason for his symptoms. The Court stated that these reports “lack the credibility normally attributed to physicians who have personally observed a patient.” In addition, the Court reiterated precedent that does not require objective evidence of a medical condition when there is no objective evidence possible for a claimant to provide.
Relevance of Social Security Administration Decision
The Court noted that the Administrative Law Judge (ALJ) for Social Security evaluated Nagy’s medical record, expert testimony and testimony of Nagy and found him disabled. The Court found this persuasive since the ALJ had “greater access to witness and expert testimony.”
Court’s Conclusion
After considering all the arguments and evidence presented by the parties, the Court held that Nagy was disabled from working in his own occupation. The court also ordered for Hartford to determine within 90 days whether Nagy was disabled from working at any occupation. The court gave short shrift to a clause included in an attachment to the policy that gave Hartford discretion to make the decision about a claimant’s disability since such clauses are against California law.
This case was not handled by our office, but it may be instructive to those who suffer from CFS and are repeatedly met with opposition from their insurers when trying to pursue their disability benefits. For any concerns about any issue concerning disability benefits, contact one of our attorneys for a free case evaluation.
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