Employee with Fibromyalgia Awarded Disability Benefits After Insurer Fails to Have Employee Examined by a Doctor

When an employee makes a claim for benefits against their disability policy, the policy language often allows the insurer to require the employee to undergo some form of examination by a medical provider. In a recent case before the United States District Court for the District of Idaho, a federal judge had to decide whether an employee was entitled to long-term disability benefits.  See Sorensen v. Hartford Life and Accident Ins. Co., No. 4:21-00286, 2022 WL 2135811 (D.ID. June 14, 2022). The employee’s doctor placed her on various restrictions due to her physical and mental health conditions including fibromyalgia, spine degeneration, anxiety and depression.

The employee in Sorensen was a truck driver and heavy equipment operator. To do her job, she was required to climb onto equipment and sit for long periods of time. Under her doctor’s restrictions, she was advised not to sit, stand or walk for extended periods of time and could not lift more than 10 pounds.

The employee eventually made a claim for disability benefits with her insurer, The Hartford. Hartford initially found that the employee was disabled under the policy. However, over time the insurer reviewed the employee’s medical history to determine whether she still remained disabled.

As part of Hartford’s review, it retained two doctors, Dr. Kakel and Dr. Nunn, to determine the extent of the employee’s physical and mental disabilities. Dr. Nunn concluded that the employee’s mental disorders exacerbated her chronic pain, fatigue and inability to focus. Dr. Kakel concluded the employee had psychiatric impairments which aggravated her medical conditions.  Hartford used the doctors’ reports to support its decision that the employee was no longer eligible for long-term disability benefits. 

The employee appealed Hartford’s denial therefore Hartford retained a Dr. Belcourt to review the denial. Dr. Belcourt noted that the employee had a significant medical history that included fibromyalgia, degenerative disc disease, arthritis, anxiety disorder and depressive disorder. His findings showed that the employee had functional limitations regarding sitting, standing and walking.  Ultimately, Hartford, relying on Dr. Belcourt’s recommendations and review, denied the employee’s appeal, concluding she was not physically disabled and was able to perform “any occupation.” 

Once the employee sued Hartford, a federal judge reviewed the record evidence to determine if Hartford had abused its discretion in denying the employee’s disability claim. After thoroughly reviewing the evidence, the court found Hartford abused its discretion.  Many factors weighed in the employee’s favor, however, the court emphasized in its decision how Hartford failed to have the employee examined by a doctor or psychiatrist as part of its review.

The court noted how under the disability policy, Hartford has the option to require the employee to submit to an examination by a physician, vocational expert, functional expert or other medical professional. Despite having the discretion for a review, Hartford chose not to use this option at any point in the four years it was reviewing the employee’s claim.  As the judge explained, “none of The Hartford’s hired experts conducted an in-person independent medical evaluation to assess the disability impact of [the employee’s] multiple diagnoses.” 

The court held that although conducting in-person exams are not mandatory in making a disability determination, it is a relevant consideration for the court when dealing with medical conditions that are not susceptible to objective verification.  Fibromyalgia, for example, is a medical condition that some medical providers contend is not able to be objectively verified through diagnostic testing such as MRIs or CT scans.

The court, in finding that Hartford abused its discretion in its denial of the claim, found it “troubling” that Hartford did not conduct an in-person evaluation. When Dr. Belcourt and Dr. Rea suggested a lack of objective findings related to the employee’s fibromyalgia, the court found they had improperly ignored her subjective complaints.