Partners Healthcare System Ignored Functional Capacity Evaluation Results in Terminating Disability Benefits for Massachusetts Nurse
A Massachusetts Court found that Partners Healthcare System (“Partners”) failed to consider the significance of a Functional Capacity Evaluation (“FCE”) before it terminated a nurse’s long-term disability (“LTD”) benefits.
Background
Ms. Solari had worked as a nurse for thirteen years when she began experiencing multiple symptoms including constant fatigue, sudden onset tachycardia (racing heartrate), flushing, rapid weight loss, and daily fevers, to name just a few. Ms. Solari’s primary care physician referred her to various specialists for further testing, which confirmed her diagnoses of postural orthostatic tachycardia syndrome (“POTS”) and mast cell activation syndrome (“MCAS”).
The LTD Claim
As part of her compensation, while working for Partners, Ms. Scolari was provided with coverage under a self-funded LTD plan. With the support of her treating physicians, Ms. Solari was forced to stop working and file a claim for LTD benefits in 2010. The request was approved by Unum Life Insurance Company, the plan’s claims administrator.
In its role as claims administrator, Unum continued to review Ms. Solari’s treatment and ongoing eligibility for LTD benefits from 2010 to 2017. Despite Ms. Solari’s doctors’ consistent reports that her condition had not improved and that she was still unable to return to work, Unum terminated her benefit payments in October 2017. Unum based its decision on the opinion of two of its physicians that the restrictions and limitations from Ms. Solari’s doctors were “inconsistent with the medical evidence.”
Ms. Solari submitted letters of support from two of her treating physicians along with her appeal, which Unum denied on May 15, 2018. After receiving Unum’s second denial letter, Ms. Solari underwent an FCE that confirmed that she did not have the physical ability to perform sedentary work.
Ms. Solari submitted the FCE, alongside other evidence, with her next and final appeal to Partners, as the plan sponsor. In denying the appeal, Partners discounted Ms. Solari’s “subjective reports” and determined that her fatigue was “subjective in nature” and “attributable to [her] considerable weight gain and deconditioning.”
The Lawsuit & Court’s Decision
Ms. Solari filed a lawsuit against Partners in Massachusetts federal court seeking reinstatement of her LTD benefits. On cross motions for summary judgment, the court held that the summary plan description (“SPD”) in place when the denial was first issued was the plan document that governed the matter. Also, the court explained that because a de novo standard of review applied to the insurer’s denial of benefits, the terms of the SPD must be strictly interpreted against the insurer and in favor of Ms. Solari.
In brief, the court concluded that:
- The objective medical evidence established that Ms. Solari suffered from both POTS and MCAS;
- While Ms. Solari’s doctors could not explain her fatigue solely by reference to these diagnoses, the record contained evidence supporting her claims of disabling fatigue;
- During the FCE, Ms. Solari’s pulse doubled to 180 while performing a sedentary task; and
- A final decision in the case could not be made until the parties adequately addressed the significance of the FCE with respect to the ultimate question of whether Ms. Solari was disabled under the LTD Policy.
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