This case involves James Ampe (“Ampe”), a Senior Development and Test Engineer employed by MIT Lincoln Laboratories (“MIT”). Ampe’s job duties included not only traditional electrical engineer work but regular client interactions. He was employed by the company from 2008 to January 26, 2015.
Around August 2011, Ampe injured himself when he fell and hit his head in his home bathroom. Subsequent to this injury, he began to experience issues with focusing in loud environments, inability to concentrate, and cognitive fatigue. Ampe consulted Dr. Sheba Khumbani, a neurologist, and she found that Ampe was “functioning in the average range for verbal abilities and in the very superior range for visual-spatial skills” and that he “experienced a significant decline since the possible concussion and his residual symptoms, including physical, cognitive, and emotional/behavioral changes, are consistent with what is often seen in post-concussive syndrome.”
Regardless of Dr. Khumbani’s diagnosis, Ampe remained at work and occasionally took FMLA leave. Over the next few years, Ampe’s performance reviews decreased in quality. After a particularly poor review in 2014, the company stated that it would no longer offer accommodations to Ampe and suggested that he seek long-term disability (LTD) benefits with The Prudential Insurance Company of America (“Prudential”). Ampe sought LTD benefits on February 14, 2015. MIT’s Plan defined disability as follows:
“You will be considered totally disabled if you are prevented by bodily injury, sickness, disease, or mental disorder from engaging in your own occupation. After the first 24 months, you will be considered totally disabled only if you are prevented by bodily injury, sickness, disease, or mental disorder from engaging in any occupation for which you are reasonably fitted by education, training, or experience.”
When Ampe began to gather information for his LTD claim, he reached out to his treating physician, Dr. Seth Hermann. Dr. Hermann stated that Ampe “continues to be limited by post brain injury symptoms, especially dizziness, fatigue, headache, nausea, confusion, [sic] irritability. He is not able to tolerate work and 32 hours or more of work is not medically feasible.” He further stated that
“Mr. Ampe’s post-concussion syndrome symptoms and condition are causally related to his fall on 8/29/2011 . . . . Some patients never return to [sic] prior level of functioning. What we do know is that up to 5 to 15% continue to suffer persistent post concussions symptoms.”
Later, on April 27, 2015, Prudential’s Vice President and Medical Director, Dr. Rajesh Wadhwa, rejected Ampe’s LTD claim. His reasoning stemmed from a belief that Dr. Khumbani failed to perform “validity testing” for her diagnosis and that Dr. Hermann’s report and other physical therapy records were “not relevant and current.” Dr. Wadhwa, however, asked that Prudential “please consider [a] fresh neuropsychiatric IME.” MIT did not wish to pay for this exam, and Ampe offered to assist with the cost; his offer was declined. On May 11, 2015, Ampe’s claim was formally denied for the reasons that Dr. Wadhwa gave.
On October 18, 2015, Ampe received a determination from the Social Security Administration (SSA) that he was disabled. The SSA relied on the assertions of Dr. Albert Berkowitz who stated that Ampe exhibited cognitive limitations, including difficulty with “hold[ing] information in [his] mind while using it to resolve a new or different challenge.” This was further supported by Ampe’s issues relating to concentration, attention, focus, and executive functioning. Ampe then decided to appeal his denial, supported by additional information.
This time, Ampe included records from Dr. Hermann, Dr. Berkowitz, and James Parker, CVRP, CRC, who evaluated vocational parts of the SSA disability claim. Upon review by Prudential’s Chief Medical Officer, Dr. Richard Day, there were further issues with Dr. Khumbani’s original diagnosis. Dr. Day suggested that Dr. Khumbani’s report be evaluated by an additional neuropsychologist prior to a final decision for the appeal. Subsequently, Dr. Kristin Fiano, a board-certified neurologist, was retained by Prudential to evaluate Ampe’s file. She opined that “overall, the record does not provide compelling support for psychological or cognitive symptoms.” Further, Dr. Fiano was critical of both Dr. Khumbani’s and Dr. Berkowitz’s failure to conduct appropriate validity testing.
Based on Dr. Fiano’s review, Prudential suggested that MIT deny the appeal; MIT agreed and did so. Ampe opted to appeal again on June 8, 2016. This time, Ampe provided a neuropsychological evaluation from Dr. Kaaren Bekken. The evaluation showed that Dr. Bekken conducted a number of tests, and she opined that Ampe’s prognosis was “poor” and found that “the patterns of deficits indicate[ ] that he is permanently disabled from . . . gainful employment.”
When Dr. Fiano was again asked to review Ampe’s file, she suggested that Dr. Bekken relied on outdated literature for her diagnosis. She further alleged that there was another issue of validity testing, and even opined that there was a possibility of psychosomatic symptoms. Prudential again suggested that MIT deny the appeal, which it subsequently did. That denial led to the instant case brought by Ampe against Prudential.
Once the court began to review the claims of this case, it came across two main issues. Firstly, the court felt that Prudential gave more weight to Dr. Fiano’s opinions than those of Dr. Hermann, Dr. Khumbani, Dr. Berkowitz, and Dr. Bekken. More specifically, the court held that it was questionable for only Dr. Fiano’s skeptical opinion to so heavily outweigh that of a treating physician and three examining specialists who had seen Ampe over a period of time. Secondly, the court believed that Prudential failed to investigate Ampe’s limitations regarding his electrical engineer job. Prudential did not show any evidence of considering Ampe’s claims of severe headaches and fatigue and how that directly impacted his work duties.
As a result of the above two issues, the court denied both motions Ampe and Prudential had filed against one another. Because the court could not force the finding of disability, it ordered a remand for a better examination and review of all of the evidence submitted by Ampe.[Note: this claim was not handled by the Ortiz Law Firm. It is merely summarized here for a better understanding of how Federal Courts are handling long term disability insurance claims.]
Here is a copy of the decision in PDF: