The case Meghan Christmas v. Sun Life Assurance Company of Canada was decided by the U.S. District Court for the District of Connecticut on December 13, 2018.
In this case, Meghan Christmas (“Christmas”), a Manager of Global Solutions Integration for ISGN Corporation, sought Long Term Disability (“LTD”) benefits from Sun Life Assurance Company of Canada (“Sun Life”). Between the years of 2012 and 2015, Christmas was diagnosed with a number of health issues; of those included psoriasis, back and joint pain, fatigue, arthritis, fibromyalgia, and several gastrointestinal issues (more particularly, Crohn’s disease, reflux, and irritable bowel syndrome). She later filed a claim for LTD benefits in 2014, which Sun Life initially denied; Christmas then sought to appeal, which also resulted in a denial. Her pursuit to overturn the denial of her benefits is the crux of this case.
Christmas submitted both medical records and opinion evidence in support of her claim, including two statements from a Dr. Skola dated June 6, 2014, and November 6, 2014, respectively. The June 2014 statement noted her psoriatic arthritis, right and left wrist synovical tenderness, bilateral hand stiffness, foot plantar fasciitis, and low back stiffness. With respect to limitations, Dr. Skola opined that Christmas could not stand or walk at all, could sit for only one to three hours a day, and could drive for only one to three hours a day. He further opined that she was unable to perform “fine manipulating” and restricted her from lifting more than ten pounds. He stated that she was “unable to work due to active psoriatic arthritis” and classified her with a Class 5 rating for her physical impairment rendering her “incapable of minimum (sedentary) activity.” Dr. Skola concluded that Christmas is unable to work within the limitations described in any capacity and that her limitations are permanent.
After denying her initial claim and when Christmas sought to appeal, Sun Life hired National Medical Review, Co. Ltd. (“NMR”) to evaluate and review the records provided by Christmas’ physicians: Dr. Michael Karasik, gastroenterologist, and Dr. Christopher Skola, rheumatologist. NMR’s three physicians, Steven Channick, M.D., David Hoenig, M.D., and D. Dennis Payne, M.D. assessed Christmas’ situation according to their own knowledge and expertise in their respective fields. As a result of those evaluations and in harmony with its initial findings, Sun Life denied Christmas’ appeal for LTD benefits.
The three physicians stated that Christmas’ medical records did not indicate sufficient evidence of her claims for disability. Further, they remarked that there were no major changes to her conditions prior to or after 2014, nor was there enough information to support her grievances, restrictions, or diagnoses. Each of NMR’s physicians explained their findings as follows:
Dr. Steven Channick, Board Certified in Internal Medicine, articulated that Christmas’ records did not point to a diagnosis of Crohn’s disease. Alternatively, he observed that she had irritable bowel syndrome. Though Christmas’ gastroenterologist Dr. Karasik diagnosed her with Crohn’s disease, her second gastroenterologist argued that he was unconvinced that she had Crohn’s. Further, a third gastroenterologist additionally stated that he did not believe Christmas’ symptoms indicated Crohn’s either. Aside from the lack of Crohn’s indicators, Dr. Channick felt that Christmas had “no restrictions needed for the work place other than free ability of bathroom breaks for her IBS symptoms” and “there were no diagnoses that would cause fatigue that would prevent sedentary employment.” Christmas’ own Dr. Karasik previously stated that while she experienced abdominal and joint pain on a daily basis, she did not have any physical limitations.
Dr. Hoenig, Board Certified in Neurology and Pain Medicine, examined Christmas’ records and noted no relevant neurological treatment history or diagnoses during the period in question, no documentation of neurological pathology, and no documentation of neurological deficits. Dr. Hoenig then suggested that Christmas was not limited in full-time sedentary work and that her condition did not “appear to be primarily neurological.” His assertions are supported by Christmas’ records which allege that there were limited neurological examinations during her doctor visits. Further, Christmas’ neurosurgeon Dr. Howard Lantner indicated that while she may have experienced some pain, she had the ability to move about without difficulty overall. Dr. Sharon Katz, a rheumatologist who also examined Christmas, stated that she had a “[f]ull range of motion of the cervical spine. No tenderness with palpitation of the vertebral column. No sign of synovitis.”
Dr. D. Dennis Payne, Board Certified in Internal Medicine and Rheumatology, opined that there was no diagnosis of a rheumatological condition which would prevent Christmas from working or would limit her functionality. Further Christmas’ lab results and medical records did not support a rheumatological diagnosis. Though Christmas saw Dr. Skola and Dr. Katz, they both indicated that she had a full range of motion and that she appeared to be comfortable and without distress.
In sum, the Court held that Sun Life’s reliance upon the three independent reviewing physicians’ assessments when denying Christmas’s claim for LTD benefits, was not arbitrary and capricious: “Indeed, these assessments and the medical records that they were based upon provide well more than substantial evidence to support Sun Life’s denial of benefits.”
The Court further rejected several arguments set forth by Christmas. First, Christmas argued that the requirement of objective proof is not included as a requisite under the Plan and therefore cannot be a basis upon which benefits are denied. The Court rejected this argument, stating bluntly “she is incorrect”.
“’[I]t is not unreasonable for ERISA plan administrators to accord weight to objective evidence that claimant’s medical ailments are debilitating in order to guard against fraudulent of unsupported claims of disability.’ [citation for quotation omitted]. Thus, Sun Life is entitled to require Plan participants to submit objective medical evidence to support a claim of total disability.”
Christmas also argued that Sun Life should have requested an Independent Medical Examination (“IME”) of her and that its failure to do so was arbitrary and capricious. The Court rejected this argument as well.
“[T]he Second Circuit has held that “requiring the plan administrator to order an IME, despite the absence of objective evidence supporting the applicant’s claim for benefits, risks casting doubt upon, and inhibiting ‘the commonplace practice of doctors arriving at professional opinions after reviewing medical files,’ which reduces the ‘financial burden of conducting repetitive tests and examinations.’” [citation omitted] Thus, in the absence of objective medical evidence to support a claimant’s disability, the plan administrator is not required to request an IME and the failure to do so is not considered arbitrary and capricious.”
This quote summarizes the Court’s overall opinion of the case: “As discussed above, the objective evidence plainly supports Sun Life’s conclusion that Christmas was not disabled.” As a result, the court granted judgment in favor of Sun Life and against Christmas.[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: