In Bombassei v. The Lincoln National Life Insurance Company, No. 22-10593, 2023 WL 3605968 (E.D. Mich. May 23, 2023), Michigan Eastern District Judge Denise Page Hood granted judgment to Plaintiff on her ERISA claim for LTD benefits, finding that Plaintiff remained totally disabled from any occupation due to her medical conditions, in particular, narcolepsy for which there is no cure or possibility of remission.
Plaintiff was employed for over 20 years as a nurse and nurse practitioner, but ceased working on September 4, 2018, due to a shoulder injury, rheumatoid arthritis, and narcolepsy. Lincoln approved and paid LTD benefits for 24 months, finding that Plaintiff was disabled from her “Own Occupation.” Plaintiff was also awarded Social Security Disability (“SSDI”) benefits, when an impartial vocational expert concluded that Plaintiff had less-than-sedentary functional capacity, particularly because she had to lay down 20% (2 hours) of the workday. Lincoln terminated benefits at the end of the “Own Occupation” period finding that Plaintiff had at least sedentary work capacity in other identified clerical occupations and upheld that decision on appeal.
In her motion for judgment, Plaintiff argued that she has a long medical history of uncontrolled rheumatoid arthritis and severe narcolepsy, both of which are supported by objective evidence. Plaintiff further argued that Lincoln’s medical reviewers did not consider her self-reported symptoms, contrary to the requirement that “file reviewer … perform a comprehensive, rather than selective, review of the records when rejecting claimant’s self-reported symptoms.” Bennetts v. AT&T Integrated Disability Serv. Ctr., 25 F.Supp.3d 1018, 1031 (E.D. Mich. 2014) (citing Ebert v. Reliance Standard Life Ins. Co., 171 F.Supp.2d 726, 740 (S.D. Ohio 2001)). Plaintiff further noted that Lincoln’s last two medical reviewers failed to consider reports from her and others regarding excessive sleepiness, instead relying only on medical records without context. Those reports evidenced that Plaintiff was suffering to stay awake throughout the (work)day, was exhausted, and fell asleep while working with patients and when talking to her daughter.
Lincoln questioned the validity of the Social Security determination because it was made in March 2020, a year before the claimed current disability period commenced, and was based on the opinion of a psychologist who had not seen Plaintiff since November 2018. Lincoln further argued that none of Plaintiff’s treating physicians opined that her narcolepsy, arthritis, or any other diagnosis prevented her from working in a sedentary occupation during the relevant time period. And, none of Plaintiff’s treating physicians returned updated Attending Physician Statements as requested by Lincoln. Moreover, Plaintiff’s treating physicians failed to provide and/or comment on then-current restrictions or limitations, and her pulmonologist never opined that Plaintiff’s narcolepsy precluded her from working. Finally, Lincoln argued that testimonials from friends and family members do not constitute proof required to prove disability.
The Court found that Plaintiff remained totally disabled pursuant to the “Any Occupation” disability standard under the policy. Like the Social Security Administration, the Court concluded that Plaintiff has, and continues to have, severe impairments consisting of rheumatoid arthritis, left shoulder disorder, depression, and especially narcolepsy. The Court found that Plaintiff demonstrated that she suffered and continues to suffer from narcolepsy to the extent that she cannot perform “the Main Duties of any occupation which … her training, education or experience will reasonably allow.”
The Court noted that Plaintiff’s doctors opined that daytime naps are necessary for Plaintiff to function, and that Plaintiff would be expected to be absent four or more days a month and be off task 20% of the workday. The Court found that all of these facts were consistent with the Social Security functional restriction reflecting that Plaintiff must be able to lay down for up to two hours during the workday, and that this nap requirement precludes Plaintiff from performing the main duties of pretty much any occupation, as one fundamental condition for performing an occupation is being awake.
The Court found it notable that the reports and opinions of Lincoln’s physician reviewers lacked any in-depth analysis regarding Plaintiff’s narcolepsy and, in fact, most of them failed to even acknowledge or discuss Plaintiff’s narcolepsy. The Court recognized Lincoln’s contention that it did not receive new Attending Physician Statements from treating providers but noted that none of the physicians from whom Lincoln sought updated statements treated Plaintiff’s narcolepsy, which is the critical basis for finding that she is totally disabled. Finally, the Court reported, to the extent that any of Plaintiff’s physicians failed to update Lincoln regarding Plaintiff’s narcolepsy, the Court was not troubled because there is no evidence that narcolepsy is curable and/or goes into remission.
As this case demonstrates, it can be difficult to convince insurers of continued disability even after the insurer has approved your LTD claim and with continued treating physician support. Our firm did not represent the plaintiff in this matter. If Lincoln has denied or terminated your disability insurance claim, contact us for assistance.
*Please note that this blog is a summary of a reported legal decision and does not constitute legal advice. This blog has not been updated to note any subsequent change in status, including whether a decision is reconsidered or vacated. The case above was handled by other law firms, but if you have questions about how the developing law impacts your ERISA benefit claim, the attorneys at Roberts Disability Law, P.C. may be able to advise you so please contact us.
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