The U.S. Court of Appeals for the Sixth Circuit recently held in favor of a long-term disability (LTD) claimant whose insurance company denied his claim based largely on severe, chronic back pain. Disability insurance companies often improperly discount credible complaints of pain.
Insurance companies will typically question reports of pain by alleging that the claimant’s medical condition does not support the reported pain level. In effect, carriers often claim that claimants are exaggerating their pain or lying about their limitations to avoid work and obtain benefits.
This case – Bruton v. American United Life Insurance Corporation – falls into this category. But the court explained why the claimant’s evidence reliably showed the seriousness and credibility of his complaints of pain.
IT manager with severe pain
Jesse Bruton was a technology development manager who stopped working because serious back and leg pain prevented him from being able to tolerate sitting for prolonged periods of time. He had disability insurance through his employer. After an approved period of short-term disability, American United (through its contracted claims administrator DRMS) denied his long-term disability application. An administrative appeal was submitted, but the denial was upheld.
Bruton filed an ERISA lawsuit in a federal District Court, which agreed with the claim denial. He then appealed to the Sixth Circuit, where he was finally successful.
Preponderance of evidence supported debilitating, disabling pain
Under the policy, Bruton would be disabled and eligible for benefits if his impairments prevented him from working in his “regular occupation,” which the parties agreed was sedentary work. The insurance company said that Bruton’s records supported a finding that he could work full time at a sedentary level, which he “dispute[d] ardently.”
Decisions about the quality of medical evidence may not be arbitrary or unsupported
The court clarified that a claimant’s treating doctor’s opinion does not automatically carry more weight than that of a nontreating physician. However, the insurer may not “arbitrarily” discount “reliable evidence,” including a treating doctor’s conclusions.
Similarly, “documented limitations” may not be characterized as “subjective exaggerations” without a reasonable basis, especially when such “credibility determinations” are made by people who never met or examined the claimant (like an insurance company’s staff, nurse or doctor).
Pain is subjective but can be objectively supported
Because pain level cannot be quantitatively measured, insurance companies often wrongfully dismiss reports of serious, disabling pain. It makes it easy to suggest that the claimant is exaggerating or that there is not sufficient support to establish that the claimant is disabled.
In Bruton’s case, the court said that his “subjective level of pain [was] well-documented.” He had consistently reported year after year “debilitating and increasing” pain.
Evidence also objectively (measurable without regard to his subjective experience) supported Bruton’s reported pain level:
- A pain specialist performed several tests to detect pain and observed no physical signs that would suggest malingering.
- His treating doctor felt the claimant was disabled based on monthly exams and MRI results.
- There was no basis for the insurance company’s doctors’ conclusions (who never meet him) that Bruton’s pain levels were unsupported when his treating doctors disagreed.
- Bruton’s long search for pain relief through multiple treatments and many medical consultations supported his claims of severe pain – it would be “highly improbable” for him to have done this just to try to get disability benefits.
- He was probably not a “good enough act[or]” to fool the medical professionals who treated him for extreme pain, including with serious medications.
The court concluded that Bruton’s pain in combination with the “cognitive effect” of his pain medication kept him from working at his regular job, ordering that the insurer pay disability benefits. This case is a strong example of why it is necessary to assemble and submit the right information when applying for disability insurance benefits or appealing a claim denial.
At Disability Insurance Law Group, we work closely with our clients and their medical professionals to obtain the appropriate information to support their claims. This includes obtaining independent medical or vocational reports, Functional Capacity Evaluations, Neurocognitive testing, and written or video testimony from physicians and other witnesses. If you have questions regarding your disability insurance claim or policy, contact us.