Disability Denial Upheld – MS, Fibromyalgia, Lyme Disease Diagnosed

In Hamilton v. Standard Insurance Company, the Fifth Circuit Court of Appeal upheld the insurer’s decision to deny long-term disability benefits to a disabled worker.  In this case, a phone company employee submitted a claim for long-term disability benefits alleging MS, fibromyalgia, and Lyme disease.  The long-term disability insurer denied the claim and the Court’s upheld the decision.  Based on my reading of the case, I would have to agree that the Court made the correct decision in this case.

This case illustrates a number of issues that you should be aware of if you need to apply for long-term disability benefits.  We will discuss each issue here.

Objective medical tests are required to support your doctor’s opinion

Ms. Hamilton’s family doctor diagnosed her with MS (multiple sclerosis), fibromyalgia, and possibly Lyme disease.  The only medical test performed by the family doctor came back negative for Lyme disease.

The family doctor did not perform diagnostic testing for fibromyalgia and MRI’s came back negative for MS.  In short, the file submitted to the insurance company for review did not contain any evidence which could minimally support the family physician’s diagnosis.

So what should you take away from this – a doctor’s opinion/diagnosis is not sufficient by itself to convince the insurer that you are disabled.  The opinion/diagnosis must be supported by recognized and appropriate tests to confirm/support the diagnosis.

A medical specialist should be utilized where possible

Ms. Hamilton’s family doctor diagnosed her with MS, fibromyalgia and Lyme disease.  While such diagnoses are well within the ability of the family doctor, these disabilities are better diagnosed and treated by specialists in the field.  A specialist’s opinion will hold more weight with both the insurance company and the court.

In this case, when the insurance company had the claim reviewed, it turned to specialists in the respective field to determine if the necessary testing was performed and if the results supported the diagnosis.  A rheumatologist evaluated the fibromyalgia claim for the insurance company and a neurologist evaluated the MS claim.  Both were board certified according to the opinion.

I take away from this that the court found it important enough to mention the board certification that you should find it important.  Plus, if you have a board certified doctor on your side, the court’s decision may be a little more difficult.

Pay attention to Appeal Deadlines

Here, the appeal was not submitted for over 2-years after the initial denial.  Luckily for Ms. Hamilton, the insurance company agreed to evaluate her appeal even though it was late.  The insurance company would have been well within its rights and the law to refuse to review the appeal due to its lateness.  And there would have been nothing that Ms. Hamilton could have done about it other than take the case to court.

Also, the court notes the lateness and so it did not go unnoticed.  By ignoring the deadlines and not requesting extensions in writing (and receiving a response in writing), you are giving the court an impression about your credibility and reliability.  Do you think it’s a good impression?

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One of your goals in appealing a denial to the insurance company is to provide them with enough sufficient and objective evidence to make it difficult for their doctors/consultants to rationalize a determination that you are not disabled.  Ms. Hamilton did not do that unfortunately.

I do feel bad for her because it does seem she was disabled and truly could have used her long-term disability benefits.  An attorney familiar with long-term disability claims and the process could have helped her make her appeal timely, provide more necessary information to support her diagnosis, and maybe helped her win her case.