It’s a fibromyalgia case. These can be especially difficult because proof of disability depends on a patient’s own reports of pain. Second, Ms. Finnerty had been approved for Social Security disability benefits. If she was disabled for Social Security purposes, why was she not disabled under the Quest Diagnostics Incorporated Long Term Disability Plan and the Quest Diagnostics Incorporated Group Life Insurance Plan?
Marisa Finnerty v. Life Insurance Co. of North America
In February 2015, Marisa Finnerty’s doctor certified that she was disabled because of insomnia and fibromyalgia. Shortly thereafter she applied for short term disability benefits. Under the terms of the disability plan, an employee is considered disabled in the short term if she is unable to perform the material duties of her occupation and unable earn more than 80 percent of her indexed covered earnings in her regular occupation solely because of sickness or injury. This is frequently described as the “own occupation” standard. Her application and appeal were denied.
In October 2017 she was approved for Social Security disability benefits retroactive to May 2015. Later that month, her doctor prepared a statement confirming her continuing disability because of fibromyalgia, citing “pain with flexion and bending of the lower back, as well as diffuse muscle pains in the upper and lower extremities.”
She applied for long term disability benefits. Under the terms of her plans, an employee is considered to be disabled in the long term if she is unable to perform the material duties of any occupation for which she is or may reasonably become qualified on the basis of education, training or experience and unable to earn more than 60 percent of her indexed earnings. This is frequently described as the “any occupation” standard.
LINA denied her application for long term disability benefits and a waiver of the premium under her life insurance plan. She appealed both, LINA denied the appeals, and she brought this lawsuit.
Is it an “Automatic ‘No’” for Fibromyalgia Claims?
It is hard to know what else Ms. Finnerty was supposed to have done to substantiate her claim. She appears to have had consistent medical documentation of her disability, and she dutifully pursued all of the remedies available under her plans. Was it just because the diagnosis was fibromyalgia?
Fibromyalgia is a complex and somewhat mysterious disease, largely characterized by pain. Since there is no objective test for fibromyalgia, diagnosis is based on a patient’s self-reported symptoms. Long term disability insurers routinely deny or limit claims for disability benefits on this diagnosis. They essentially substitute their own, arguably conflicted, judgment for that of the patient’s physician.
But because Ms. Finnerty was awarded Social Security disability benefits on the basis of the same diagnosis, her argument may be stronger than many.
Does a Social Security Award Guarantee Insurer Approval?
The Social Security Administration defines “disability” as “the inability to engage in any substantial gainful activity by reason of any medically determinable physical or mental impairment(s) which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months.” Qualifying for Social Security disability benefits is not easy. More than half of initial claims are denied for lack of medical evidence, and success, when it comes, often happens only on an appeal.
Nonetheless, a Social Security disability benefit approval does not guarantee the same result under an insurer’s LTD plan. ERISA, the federal law governing LINA’s plans, requires that benefits be awarded as required in the plan document. For long term disability benefits, LINA’s plan, like many LTD plans, uses the “any occupation” standard set out above.
Once the dispute ripens into a long term denied disability lawsuit, courts apply either an “arbitrary and capricious” standard, which is generally quite deferential to a plan administrator’s initial decision, or they may take a fresh look at the medical evidence under a de novo standard. This may be more favorable to a plaintiff. California courts increasingly use the de novo rule.
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If Marisa Finnerty prevails, and continues to prevail through the appeals that may follow, this case may provide powerful precedent for LTD claimants who have been denied benefits under an employer’s LTD plan, even though they have Social Security disability awards. In light of the Social Security Administration’s recent openness to understanding fibromyalgia as a medically determinable impairment, this turn of events could bring at least some legal relief to fibromyalgia sufferers.