A California federal court found that Life Insurance Company of North America’s (“LINA”) denial of long-term disability (“LTD”) benefits to a Senior Manufacturing Engineer with pain and fatigue was wrong.
Ms. Christie Lopez’s Disability and Claim
Ms. Lopez’s disability claim stemmed from pain and fatigue that she attributed to her fibromyalgia and history of breast cancer. She tried various treatments including chemotherapy, radiation therapy, double mastectomy. She suffered from but it kept worsening. She treated with numerous medical professionals including a rheumatologist, neurologist, and primary care doctors. None of the treatments helped alleviate her pain and fatigue. By 2010, she was struggling to manage a full day of work because of the pain as well as the extra time needed to manage her care and treatment.
Ms. Lopez stopped working in February 2010 and submitted her claim for disability benefits. LINA initially approved short-term disability (“STD”) benefits, but eventually terminated payments. Ms. Lopez successfully appealed that decision, and LINA retroactively paid STD and LTD benefits, determining that she was disabled from her “own occupation.”
LINA later terminated LTD benefits, determining that Ms. Lopez was no longer disabled as defined in LINA’s policy.
Ms. Lopez appealed LINA’s denial. Included with her appeal were medical records from her multiple providers that documented abnormal clinical examination findings, worsening pain, and extensive treatment including physical therapy and injections. She also provided letters of support from her primary care physician, neurologist, and rheumatologist. She also submitted objective testing by way of a Cardiopulmonary Exercise Test (“CPET”)—a test to measure fatigue—that documented severe fatigue.
In response, LINA had Ms. Lopez submit to an in-person medical evaluation performed by its paid physician, who determined that she was not disabled. LINA also had Ms. Lopez’s records reviewed by a nurse and two doctors. Relying on its physicians, and claiming Ms. Lopez’s condition had improved, LINA denied the appeal. Ms. Lopez filed a lawsuit in federal court.
The Court’s Ruling
In reviewing the file, the court gave significant weight to Ms. Lopez’s treating providers over LINA’s reviewing physicians as well as her self-reports of fatigue and pain. The court also considered the extent of Ms. Lopez’s treatment history with her doctors, LINA’s reviewer’s opinions in light of the medical evidence, and how much detail Ms. Lopez’s doctors provided supporting disability. All factors weighed in favor of the treating doctor’s opinions being reliable and credible.
In contrast, the court gave less weight to LINA’s reviewing physicians—even when one personally examined Ms. Lopez—because they consistently misstated or selectively cherry-picked parts of the medical records to support a finding of not disabled. For these reasons, the court ruled in favor of Ms. Lopez.
Help from a Lawyer with Expertise in Disability Insurance
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