Farooq Khan, M.D. (“Khan”), is a neurologist who filed for long term disability insurance benefits. Provident Life and Accident Insurance Company (“Provident”) denied Dr. Khan’s LTD claim. After exhausting his appeals directly with the insurance company, Dr. Khan filed suit against Provident for breach of contract, asking the court to award payment of his long-term disability benefits. Dr. Khan was a board-certified neurologist with a history of medical issues that extended back to 2005. The records range from then until mid-2014, with treatment from a minimum of twelve doctors – seven of whom are rheumatologists. Not a single treatment provider in the record stated that Dr. Khan would be able to continue his work as a neurologist.
In 2005, Dr. Khan had been experiencing symptoms of proteinuria, including “significant general fatigue” and arthralgia of the right knee without inflammation. At this time, an MRI was advised but never obtained. There was a bone scan, but it did not provide a definitive diagnosis of a rheumatological problem. By 2006, Dr. Khan continued to complain of arthralgia in the right knee, as well as followed up on the proteinuria. Dr. Lipson ordered that another bone scan be done, but there was no definitive diagnostic impression.
Dr. Khan saw a new rheumatologist in 2007. Dr. Liu examined Dr. Khan and opined that his negative rheumatoid factor and benign joint exam “goes against rheumatoid arthritis that can manifest as scleritis,” but he “certainly would keep it within the differential diagnosis.” Dr. Liu also noted that Dr. Khan’s repeat serology was not unusual. By 2008, Dr. Wu had examined Dr. Khan for both the occasional elbow pain and right patellar discomfort. However, Dr. Wu also stated that there was “no overt inflammation” and “no active joints.”
By March 18, 2009, Dr. Khan had been seeing Dr. Simon Carette, but Dr. Carette stated that it was “quite difficult to provide a unifying diagnosis.” Further, Dr. Wu wrote “[q]uery microscopic polyanginitis or Wegener’s granulamatosis” in relation to a possible renal diagnosis. Dr. Khan did not provide information for the next years, citing a report of fatigue in 2012. However, in 2013, Dr. Khan had a rheumatology evaluation done by Dr. Ernesto Levy. Dr. Levy opined that “[a]s of now, his illness remains undiagnosed[,]” but “[s]ome of the described features would have the prints of an inflammatory rheumatologist condition (scleritis, abnormal urine); however, some other features are less specific (fatigue, dizziness).” In 2014, Dr. Khan saw two new rheumatologists after he filed for a disability claim. Both of those doctors opined that Dr. Khan was totally disabled.
Since 2011, Dr. Khan had been covered by a disability benefits policy. He stopped working at the Hospital on June 9, 2013, and applied for disability benefits the next day based on relapsing polychondritis and polyarthralgias. To support his application, Dr. Khan submitted an Attending Physician Statement from a Dr. Moreland. Dr. Moreland opined that Dr. Khan was able to walk, climb, sit, stand, twist/bend/stoop, operate heavy machinery “occasionally” and reach above shoulder level. However, Dr. Moreland also stated that Dr. Khan was “unable to work” and that “no improvements” to his condition were expected.
Then, Provident had a Senior Vocational Resource Consultant, David Gaughan, examine Dr. Khan’s file. Gaughan determined that there were “[c]ognitive considerations” to Dr. Khan’s job, but primarily the job included following medical standards and protocols, paying attention, executing medical judgments, and clearly communicating in both writing and speech. On December 11, 2013, Dr. Khan received a letter from Provident denying his claim for benefits. More specifically, the letter cited that the “medical information . . . received does not support an impairment that would prevent him from being able to perform the duties of his occupation. As such, he is not eligible to receive Total Disability benefits, Residual Disability benefits, Recovery benefits or Waiver of Premium.” At this point, Dr. Khan filed an administrative appeal, submitting additional documents and more medical opinions. Dr. Stone, a rheumatologist, opined that Dr. Khan’s conditions of polychronditis and symptoms resulted in a total disability from his occupation.
According to the Social Security Administration (“SSA”), Dr. Khan claimed that his disability was due to relapsing polychrondritis with arthralgia and fatigue. The SSA decided that Dr. Khan’s issues were “so severe that he is limited to significantly less than full range of sedentary work,” categorizing him as disabled under its own standards. However, when Provident had a medical consultant examine Dr. Khan’s file, Dr. Beth Schnars stated that his issues “do not rise to the level of impairment from or since the [date of disability]” because Dr. Khan’s treating physicians’ medical opinions were “based on self reports of long standing fatigue without supporting evidence of abnormalities on exam or lab findings and lack of aggressive medical management.”
Provident then sought to obtain a “no deference” medical review from rheumatologist Alfonso Bello. He reported that Dr. Khan’s diagnosis of polychrondritis was confirmed, but, “there had been no clear evidence of physical limitations based on objective clinical evidence specifically of abnormal musculoskeletal examinations that would warrant restrictions or limitations based on [a] reasonable degree of medical knowledge.” On December 17, 2014, Provident denied Dr. Khan’s appeal, citing most of its reliance on Dr. Bello’s statements.
This led to the instant suit by Dr. Khan. Dr. Khan’s first argument is that Provident required objective proof that is not imposed by the policy. Provident relied on its Disability Policy which cites “any evidence” as the type of written proof that is required. Because that terminology is so vague, Provident utilized that ambiguity to interpret it to mean objective proof. The court disagreed with this interpretation and found it to be contrary to the purposes of ERISA. Dr. Khan’s second argument is that Provident chose to ignore his subjective complaints. In fact, Provident had the ability to do an in-person medical evaluation but failed to do so. Therefore, the court felt that the repeated efforts to review paper-only examinations led to actions that were arbitrary and capricious.
Lastly, Dr. Khan argued that Provident did not properly consider evidence of his job requirements and whether he could perform same. The court agreed with this assertion, stating that Dr. Khan did prove by a preponderance of the evidence that he was unable to perform his job duties under the “Your Occupation” standards. For each of the above reasons, the court agreed with Dr. Khan, ultimately deciding that he should be awarded long-term disability benefits.[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: