Can an Employee’s Complaints of Pain Lead to Coverage Under a Long-Term Disability Plan?
Feb. 21, 2023
When an employee submits a claim for long-term disability benefits, one of the primary factors a disability insurer considers is what the employee’s doctors conclude about the employee’s condition as reflected in the medical records. For example, insurers often look for diagnostic testing such as reports, CT scans, EKGs, etc., to see if there are diagnostic tests conclusively showing an injury. Doctors treating the employee rely on these tests to diagnose and treat their patients. Doctors also use such testing to support their conclusions on whether the employee is disabled and unable to return to work.
The opinions of an employee’s doctors are what disability insurers look to when considering whether an employee qualifies for disability coverage. Putting aside the opinions of the doctors, what weight, if any, do insurers give to the “subjective” complaints of the employee. Courts and insurers refer to diagnostic tests like MRIs as “objective” evidence of pain, whereas the self-reporting of employees is based on their feelings, sensations, and emotions and is commonly referred to as “subjective” complaints.
An employee in Vermont recently sued his disability insurer in federal court due to the insurer, CNA’s (later assumed by Hartford Life Insurance) decision to deny the employee’s disability benefits. In that case, the employee was receiving disability insurance benefits for almost nineteen years following a motor vehicle accident that seriously injured his neck, shoulder and lower back. The employee underwent a fusion of his lower spine, however, that procedure was unsuccessful.
Over the years, the employee treated with several doctors all of whom concluded the employee had serious limitations and was unable to work on a full time basis as a vice president with an investment firm. The employee’s disability insurer, CNA, had the employee’s claim reviewed by one of its doctors who disagreed with the conclusions regarding the employee’s inability to work. Based on this review, the insurer denied the employee’s disability benefits which led the employee to sue the insurer in federal court.
One of the issues the court looked at when reviewing the insurer’s denial was the subjective complaints of pain by the employee. CNA’s reviewing doctor disagreed with the findings of the employee’s treating doctors, in part, because the doctors were relying on the subjective complaints and limitations that the employee shared with his doctors.
When the court considered the evidence in support of the employee’s disability claim, the court noted that “testing and objective measurements are desirable,” however, “courts do not dismiss subjective self-reporting as presumptively invalid.” The court cited to other cases that recognized the subjective complaints of injured employees are important factors which courts should consider when determining disability.
Looking at the evidence before it, the court recognized how the employee’s complaints of pain were consistent with a “verifiable event” - the car accident which caused the employee’s initial injuries and subsequent symptoms of pain and inability to work.
Taking all the evidence together, the court found that a denial of benefits needed to be based on a change in the employee’s medical condition. There, the court found that the evidence presented failed to show a change in the employee’s medical condition. Over an 18 year period, the evidence consistently showed the employee was disabled due to his medical condition.
The decision is Curiale v. Hartford Life & Accident Ins. Co., No. 2:21-cv-54, 2022 WL 2063261 (D.Vt June 8, 2022).