Brown v. LINA – Can A Peer Review Physician Outweigh My Physician’s Opinion?

Case Name: Brown v. Life Insurance Company of North America

Court: United States District Court for the District of Arizona

Date of Decision: December 12, 2014

Type of Claim: Long-Term Disability

Insurance Company: Life Insurance Company of North America (“LINA”)

Claimant’s Employer: National Instruments

Claimant’s Occupation / Job Position: General Counsel / Commercial Lawyer

Disabilities: Complex Regional Pain Syndrome (CRPS) – frequently referred to as Reflex Sympathetic Dystrophy (RSD), migraine headaches, Nutcracker Syndrome, connective tissue disease, synovitis, and autoimmune ailments diagnosed as scleroderma and lupus.

Definition of Disability: Participants under the LTD Plan are eligible to receive benefits if they satisfy the terms of the Plan, which include the following definition of disability:

The Employee is considered Disabled if, solely because of Injury or Sickness, he or she is:
1.  Unable to perform the material duties of his or her Regular Occupation; and

2. Unable to earn 80% or more of his or her Indexed Earnings from working in his or her Regular Occupation.

After Disability Benefits have been payable for 24 months, the Employee is considered Disabled if, solely due to Injury or Sickness, he or she is:

1. Unable to perform the material duties of any occupation for which he or she is, or may reasonably become, qualified based on education, training or experience; and

2. Unable to earn 60% or more of his or her Indexed Earnings.

The Insurance Company will require proof of earnings and continued Disability.

Benefits Paid? LTD benefits were paid for two years and then terminated at the end of the “own occupation” period when the definition of disability converted to the “any occupation” standard.

Key Physician Opinions: The Plaintiff had numerous treating physicians who provided opinions in support of the disability claim, opining that she is disabled and providing medical documentation in support of the views.
Brown’s appeal was reviewed by Appeals Specialist Keith E. Jackson, internist Dr. Jacqueline E. Hess (a third-party physician), and Nurse Case Manager Linda Van Pelt. She was also surveilled before the FCE. A physical therapist, Ms. Lunda, conducted the FCE.

Procedural History: After her benefits were cut off, the Plaintiff timely appealed. LINA denied the appeal. The Plaintiff exhausted her administrative remedies and filed a lawsuit.

Issues: 

(1) Whether the Functional Capacity Examination was sufficient.

(2) A primary post-decision fight is whether or not the Plaintiff had cognitive impairment and was debilitated from the pain medication that she was taking. Whether applying the sedentary or occupational employment standards, pain and the medication required for pain is a primary issue.

(3) Whether the Plaintiff has satisfied her burden of proof proving disability.

Holdings: On August 14, 2012 (after benefit payments stopped but before the decision on the appeal), the Plaintiff’s primary care doctor wrote that Brown continued to be disabled and that the FCE examiner was unaware or unappreciative of the medical complexity of Brown’s condition:

“I have reviewed the Functional Capacity Evaluation (FCE) performed on February 13-14, 2012 and do not feel that it provided an adequate assessment of Rebecca’s situation. The physical skills and abilities measured by the FCE are a snapshot in time barely relevant to Rebecca’s complex overall medical conditions including the CRPS, Connective tissue Disorder, and medication-related side effects including fatigue. The mid-February timing of the FCE was immediately before a flare of symptoms from her (then) less appreciated Nutcracker Syndrome. The symptoms of pain were so severe at times at the beginning of March that I ordered additional testing and a referral to a specialist (Dr. Stephens) who referred Brown for more testing and to Dr. Trinidad who thought the condition warranted major surgery. Surgery was recommended in early April and performed May 23.”

The Court stated, “The examiner was not well informed of the complexity of Brown’s medical problems prior to the exam.” (emphasis added).

(2) “There is no basis for questioning Plaintiff’s credibility on this issue. In addition, at least three treating physicians’ opinions corroborate her pain level – from constant to flaring – and produced objective medical evidence for such.”

(3) The Court stated, “After a de novo review, the Court finds that Plaintiff has met the burden of proof based on the treating physicians’ medical opinions derived before and through March 2012. Unfortunately, the Plaintiff has diseases and treatments for these diseases that are incompatible with working in her own occupation as an attorney or any gainful occupation over a consistent period of time.
…
Consideration of Plaintiff’s pain and the treatment for pain is a significant aspect of this conclusion, in conjunction with her physical impairments. All of her treating physicians have produced objective medical evidence of an underlying impairment that would reasonably be expected to produce pain. She was being treated for the pain, and Plaintiff claims that those treatments in combination with the pain and other physical impairments have a direct impact on her ability to function on a consistent basis. There is no reason to question Plaintiff’s credibility here. The FCE consisted of over a two-day period of physical tests observed by a physical therapist and the surveillance produced evidence of relatively no activity other than driving to and from locations. The Court accepts Plaintiff’s debilitating pain as true. … The fact is that three of Plaintiff’s treating physicians opined that she is disabled and those opinions are uncontroverted; disabled under both definitions of “disabled” under the Plan.”

Summary:” IT IS ORDERED that Defendants’ motion for decision on the administrative record is DENIED and Plaintiff’s motion for summary judgment is GRANTED. A Final Judgment shall enter separately in favor of Plaintiff which should include an award of retroactive benefits calculated from March 8, 2012, to the date of this Order set off by any SSDI income received on a monthly basis.”

Note: The Ortiz Law Firm did not handle this claim. It is merely summarized here to help claimants understand how Federal Courts decide long-term disability insurance claims.

Here is a copy of the decision: Brown v. LINA