In this case, decided September 21, 2017, the U.S. District Court for the District of Colorado determined that the Life Insurance company of North America (“LINA”) wrongfully terminated Ms. Johnson’s long-term disability (“LTD”) benefits. The Court reversed the termination and found that LINA’s decision was not only wrong, but also arbitrary and capricious.
Ms. Johnson suffers from trigeminal neuralgia, which is a chronic pain condition that affects the trigeminal nerve. This nerve carries sensation from the face to the brain, so the condition can cause mild to severe facial pain, often triggered by common activities like chewing, speaking, or brushing your teeth. Because of the nature of the condition, the only evidence of the condition’s severity comes from the sufferer’s subjective complaints.
The Court was smart to recognize this fact and its repercussions immediately. If the severity of a pain condition is determined solely by the patient’s complaints, then the real question in chronic pain cases is whether the patient is credible. Here, the Court noted at the outset that Ms. Johnson’s credibility was essentially the only issue at stake.
Ultimately, the Court overturned LINA’s decision because it found that LINA had no reliable evidence detracting from Ms. Johnson’s credibility. It had no real reason to disbelieve her. Accordingly, the Court found LINA’s termination to be unreasonable.
The Court took particular issue with one piece of evidence LINA relied on – a medical evaluation report completed by Dr. Lloyd J. Thurston, D.O. Dr. Thurston concluded that Ms. Johnson’s pain complaints were not supported by objective physical examination findings. He concluded that she was significantly exaggerating her symptoms.
As part of her appeal, Ms. Johnson submitted an affidavit discussing the details of her appointment with Dr. Thurston from her point of view. She noted that Dr. Thurston was aggressive with her, telling her that she was fine, that he did not believe her, and that he had not reviewed her records. He ever referred to her “so-called disease.”
The Court found it very problematic that LINA continued to rely on Dr. Thurston’s report after receiving Ms. Johnson’s affidavit. Indeed, because LINA included Dr. Thurston’s report in the information it provided to doctors who reviewed Ms. Johnson’s file in subsequent appeals, the Court found that even those opinions were suspect.
Ultimately, the Court found that LINA had no basis for questioning Ms. Johnson’s self-reported symptoms. And, importantly, because her condition’s severity is determined nearly entirely by self-reported symptoms, the Court gave no weight to LINA’s doctors who repeatedly argued there was no “objective evidence” of her inability to work.
This is a common issue we see in cases where the client suffers from chronic pain. Often, the insurance company becomes focused on receiving objective evidence when the policy does not require it and the condition does not lend itself to traditional objective testing. This Court saw through LINA’s surface-level reviews and got to the real crux of the matter – did LINA have any reason to doubt Ms. Johnson’s self-reports? It found it did not and reversed the termination.
