Prudential denies disability benefits to man with fibromyalgia after paying benefits for 10 years

Another case heard on October 7, 2009 before the United States Court of Appeals First Circuit highlights the challenges of obtaining benefits when a claimant suffers from fibromyalgia. This case also highlights how one court can find a successful application for Social Security disability benefits as compelling evidence that a person deserves their long-term disability benefits and how another court will side with the insurance company’s argument that the plan criteria is different from Social Security’s disability criteria.

The background behind this long-term disability case.

Edward Richards worked for Digital Equipment Corporation (DEC) as a software engineer from May 1984 until January 1991. One of his employment benefits included insurance coverage under DEC’s long-term disability plan which was managed and administered by Prudential Insurance Company of America (Prudential). This plan stipulated that Richards had to have suffered a sickness or accidental injury that made prevented him from performing the material and substantial duties of his occupation for the first 24 months. After 24 months, Richards would have to demonstrate that he was unable to perform the material and substantial duties of any job for which his education, training or experience qualified him for.

In May of 1991, Richards applied for long-term disability benefits. The basis of his claim was chronic fatigue immune dysfunction and fibromyalgia which had left him unable to work after January 15, 1991. His long-term disability claim was accepted in October 1991, with payments retroactive to July 1991. Social Security awarded Richards disability benefits in 1992.

One of the requirements of the plan was ongoing proof that Richards was still disabled. This included providing regular statements of condition and releases that enabled Prudential to obtain his medical records. Richards found the requests harassing, but he complied with the requirement.

After 10 years, Prudential reviews whether disability still exists.

In January of 2001, Prudential requested medical records from three of the treating physicians that Richards had identified in his statements regarding his condition. They were seeking information that covered from January 1999 until January 2001. Prudential received a report on February 5, 2001, from one of the physicians, Dr. Carol Englender, that she had not seen him since before January of 1999. Prudential had already been considering reviewing Richards’ long-term disability claim. In their eyes, this confirmed the need to do so.

Prudential sent Richards’ file to Dr. Gwen Brachman, who practiced in the area of internal medicine, rheumatology and occupational medicine. After reviewing Richards file, Dr. Brachman found that despite Richards’ diagnosis of fibromyalgia, he was not physically impaired from performing the essential functions of a sedentary job. After receiving this report, Prudential informed Richards on March 26, 2001 that his eligibility for long-term disability benefits were denied and that his disability payments would end on June 1, 2001.

Prudential terminates long-term disability benefits.

Richards’ benefits termination letter told him what to do in order to appeal Prudential’s denial. They followed up with a second letter about a month later, which also detailed the appeals process. Over the next three years, Prudential heard from Richards quite frequently. Many calls centered on requests for details on the appeals process, but other calls included accusations of malfeasance and threats. Finally, on July 26, 2004, Richards submitted a formal written appeal of Prudential’s March 2001 decision.

The disability appeals process begins.

Richards presented three reasons that Prudential should reinstate his benefits. First, he claimed that Dr. Brachman was both unqualified to review his disability and had used improper evaluation techniques and made false statements in her review. Second, Richards argued that Prudential should have deferred to the opinions of his treating doctors. And finally, he claimed that Prudential should recognize the 1992 decision of Social Security to award him disability benefits. Prudential denied this appeal on September 28, 2004.

In the letter, Prudential responded to Richards specific complaints. They noted that Dr. Brachman specialized in occupational medicine and rheumatology. She was qualified to review Richard’s medical records. Prudential made it clear that they had considered Richards medical records and Social Security determination. They pointed out that a transferable skills analysis had concluded that Richards could perform a number of sedentary occupations which his education, training and experience qualified him for.

Richards responded by sending additional records from one of his treating physicians, Dr. Mark Hryniewich. He asked Prudential to review its decision again. Prudential did so, but reconfirmed its original decision to terminate his long-term disability benefits on February 8, 2005. Prudential informed Richards about his rights to pursue further appeals. Richards submitted a second written appeal in August 2005.

In this appeal, Richards accused Prudential of ignoring Dr. Hryneiwich’s diagnosis that Richards’ fibromyalgia left him chronically disabled, evidenced by their failure to contact the doctor. This appeal also accused Prudential of providing Richards with a legally deficient termination notice, claiming that the instructions were not detailed enough and did not provide explicit instructions about the type of information Richards needed to provide so his benefits would be reinstated.

Prudential reexamines disability claim by sending file for physician’s review.

Prudential responded by conducting another review, this time by Dr. Richard Day, the insurance company’s medical director. After receiving his report, they reaffirmed their decision to terminate Richards’ benefits, stating once again that Richards could perform the duties of a sedentary job, and that he was qualified for a number of sedentary positions. They noted that his previous neurological assessments demonstrated that there “were no rheumatological laboratory or physical findings consistent with synovitis or an inflammatory process.” Prudential referred Richards to the transferable skills analysis they had performed the previous year and also told him that Dr. Day felt his treatment plan for the chronic fatigue syndrome was incomplete, because it did not include cognitive behavioral therapy.

Man with fibromyalgia hires disability attorney.

Richards finally hired a disability attorney to represent him for Prudential’s third and final level of appeal. In the January 30, 2006 appeal letter his disability lawyer prepared, Richard’s repeated his claim that he was totally disabled and unable to perform any occupation. The disability attorney argued that the September 29, 2005 decision letter “did not set forth with the required specificity” the reasons why Richards’ benefits were discontinued. He also took issue with the recommendation for cognitive behavior therapy, comparing the recommendation to the former practice of locking epileptics up in mental asylums. The disability attorney asked to meet with Prudential’s appeals committee prior to its final determination.

Prudential responded quickly. On February 6, 2006 Prudential provided specific reasons why they felt that their decision letter had been complete. Prudential noted that they had cited policy provisions, medical reviews and vocational assessment. Prudential argued that it had no contractual obligation to contact his physicians, stating that the information needed was in his medical file. Prudential also refused to meet with Richards’ disability attorney, pointing to the fact that the committee did not meet with claimants or their representatives. The purpose of the committee was to provide a third and voluntary level of appeal review.

Richards had until April 1, 2006 to submit any materials that supported his final appeal. But communications broke down regarding deadlines, and Prudential extended the deadline to June 6, 2006. Richard used this time to supplement the administrative record. On June 5, Richards’ disability attorney submitted a report from Dr. Hryniewich which expressed his opinion that Richards had been totally and permanently disabled since 1991. It was this doctor’s opinion that his total and permanent disability would continue for the foreseeable future. He reported that Richards “tested positive for fibromyalgia.” He noted that even though the symptoms could be treated with pain medication, the side effects of the medication made gainful employment impossible.

Prudential orders another physician’s review disability claim.

Prudential sent Richards files to Dr. Paul Howard and Dr. Dayton Dennis Payne in April 2006. Dr. Howard’s conclusions, submitted to Prudential on July 6, 2006, found that Richards’ rheumatological symptoms between 2001 and 2006 were consistent with fibromyalgia, but that the symptoms should result in functional impairments that were mild in nature. Dr. Howard pointed to the fact that even though Dr. Hryniewich mentioned the side effects of pain medication, there was no mention of side effects in any of the medical records. He also noticed that Richards had not followed a recommended exercise program, which might have improved his functional capacity. Dr. Howard’s conclusion was that despite a mild degree of impairment, Richards should be able to perform sedentary work.

Dr. Payne recognized some of the issues that Richards’ condition caused such as short-term memory issues, irritable bowel syndrome, depression and possible bursitis. He found that Richards’ symptoms had remained “essentially unchanged” over the 15 years since he had begun receiving benefits. At the same time he saw no evidence of “destructive rheumatic findings.” He saw no evidence that Richards’ ability to move about was limited. He saw no evidence of weakness or atrophy. Because of this, he concluded that the record didn’t support functional impairment after June 2001.

Based on these two doctors opinions, Prudential informed Richards’ attorney of its final decision to uphold Richards’ termination of benefits on July 18, 2006. In their letter, Prudential concluded that “the medical evidence overwhelmingly supports that Mr. Richards has been capable of returning to work on a full-time basis in both his own occupation as well as in an alternative, gainful occupation since at least June 1, 2001.”

Prudential’s denial is final. The disability claim goes before the court.

Richards had exhausted his administrative remedies. His disability attorney filed suit in federal court, seeking reinstatement of his benefits retroactive to June 2001. They also sought attorneys’ fees and roughly $43,000 in sanctions against Prudential for failing to provide certain documents during the administrative process.

Would Richards’ benefits be reinstated? Or would Prudential’s decision be upheld by the court? We will look at how the court reached its decision in Man with fibromyalgia faces Prudential insurance in appeals court.