Pain can be disabling, making it impossible for people to work, engage their hobbies, or even perform activities of daily living. But pain is subjective – it can only be felt by the one who is suffering – and insurance companies sometimes deny long-term disability claims if there is little or no corroborative objective evidence.
Federal courts around the country have ruled, however, that subjective complaints of pain and disability are important factors that insurance companies must consider in determining whether to pay benefits. One case provides policyholders with a roadmap to overcome insurance companies’ defenses against subjective complaints of pain and disability.
Miles v. Principal Life Insurance Company
In the Miles case, Mr. Miles applied for long-term disability benefits under his ERISA-governed long-term disability policy, which was administered by Principal Life Insurance Company. Miles was a partner at law, and suffered from bilateral tinnitus accompanied by ear pain, hearing loss, headaches and vertigo. He claimed these conditions prevented him from performing his job duties. On his claim form, Miles said the high-frequency sound resulting from the tinnitus would wake him up at night, and that the accompanying pain and disorientation made it impossible for him to read or concentrate. His treating doctor agreed that the severity of the tinnitus disabled him. Miles also submitted medical records that included an EEG, MRIs and hearing examinations.
Principal hired doctors to examine Miles, and those doctors concluded that no “objective findings” existed to support Miles’ impairment. Referring to the wording of its policy, which stated that benefits would be payable when a plan member submitted “complete and proper proof of disability,” Principal denied the claim. After the trial court sided with Principal, the Second Circuit Court of Appeals reversed the decision.
What the court said in Miles
The Miles Court ruled that subjective complaints are “important factors to be considered in determining a disability” and that it was “arbitrary and capricious” for an insurance company to disregard evidence simply because it was subjective. If an insurance company chooses to disregard a claimant’s subjective complaints, it must state why, the court held. Simply pointing out that the evidence is subjective is not a proper basis to reject that evidence. Further, the court ruled that an insurance company may not require a claimant to obtain an objective test for a disabling condition when no such test exists. The court said an insurance company may apply lower weight to subjective complaints if it identifies other objective findings that it would reasonably have expected to see in conjunction with the subjective complaints. To assess the weight of a claimant’s subjective complaints, the Federal Appeals Court said an insurance company should rely on evidence such as diagnoses commonly associated with the subjective complaints, or a claimant’s positive past work history.
Me and my firm are proud to have created this body of law to help those suffering from disabling pain. We did so in the first case of its kind, Connors v. Connecticut General Life Insurance Company (CIGNA)
Supporting subjective claims with objective evidence
The Miles Court gives claimants a roadmap of practical steps they can take to bolster their claims against insurance companies, who typically argue that subjective complaints of pain and disability are unsupported by objective tests, or exceed what their objective test results show. Insureds should collect evidence wherever they can. This can include diagnostic tests, clinical findings with appropriate physician(s), such as orthopedists, neurologists, pain management specialists, rheumatologists, or other doctors appropriate to the condition(s) causing pain and limitations. Claimants should ensure that the physician is keeping accurate notes about how the pain is impacting their lives. It’s important to take all prescribed medications, as insurance companies will check to see that prescriptions were filled
Not all evidence is medical in nature. If claimants can demonstrate they had a successful career prior to their disability, this will enhance their credibility. If they have, say, a 20-year work history in which they took limited days off and received good reviews, raises and promotions, this will weigh in their favor. Further, co-workers, along with family members and friends, can provide statements that speak to how much the impairment has impacted the claimant’s ability to perform work or activities of daily living.
How we can help
If your long term disability claim has been denied or terminated, or is being challenged by a disability insurance company based on a lack of objective evidence, give us a call. We understand how to document and correlate your pain to support a claim, and we have the experience and knowledge to handle disability insurance companies who wrongfully challenge such claims. Contact us today for a free consultation.
Evan S. Schwartz
Founder of Schwartz, Conroy & Hack
800-745-1755
ESS@schlawpc.com