Court Remands Disability Claim for Ehlers-Danlos Syndrome

Rebecca Pifer, a former dental analyst for Blue Cross Blue Shield of North Carolina, filed a lawsuit under the Employee Retirement Income Security Act (ERISA) against Lincoln Life Assurance Company of Boston to recover long-term disability benefits.

Note: Lincoln Life typically operates under the branded name of Lincoln National.

Initially diagnosed with Ehlers-Danlos Syndrome and osteoarthritis in 2011, Pifer was approved for disability benefits in 2012 following a report from consulting physician Dr. Howard Blank, who found several permanent physical limitations.

From 2012 through 2020, Lincoln Life continued to approve Pifer’s disability claims each year, based on consistent medical evaluations that supported her inability to engage in “any gainful employment.” However, in 2021, following a video surveillance report and a new Functional Capacity Evaluation (FCE) by Anna Davidow, which suggested that Pifer could perform sedentary work, Lincoln Life denied her claim for further benefits.

Pifer appealed the denial, submitting extensive medical documentation from various physicians evidencing a worsening of her condition that contradicted the findings of the FCE.

Nevertheless, her appeal was denied after a review by Dr. Hunter Vincent, who acknowledged her functional limitations but recommended that the claimant “work in a sedentary setting on a full-time basis.”

Pifer then appealed to the United States District Court for the Middle District of North Carolina under Section 502 of the Employee Retirement Income Security Act of 1974. The court’s analysis was thorough and detailed, focusing on the standards set by ERISA for handling claims and the discretion granted to plan administrators. Here’s a more detailed breakdown of the court’s evaluation and the reasoning behind its decision to remand the case for further review:

1. Standard of Review: The court applied an “abuse of discretion” standard of review because the insurance plan granted Lincoln Life discretionary authority to determine eligibility for benefits. Under this standard, the plan administrator’s decisions are upheld unless they are found to be unreasonable.
2. Evaluation of Medical Evidence: At the heart of the case were the conflicting medical opinions of Pifer’s treating physicians and the independent medical review provided by Lincoln Life. Pifer’s physicians consistently reported worsening symptoms and debilitating pain, reinforcing her inability to work. Conversely, the FCE conducted by Anna Davidow suggested that Pifer could perform sedentary work. The court examined these conflicting reports to determine whether Lincoln Life’s reliance on the FCE over the treating physicians’ evaluations was reasonable.
3. Consideration of All Relevant Evidence: The court criticized Lincoln Life for potentially failing to consider all relevant medical evidence in making its decision. This included a symptom diary provided by Pifer that detailed her daily pain and functional limitations, which was not explicitly acknowledged in the administrator’s review process. The court emphasized the importance of considering all available evidence, particularly when the claimant’s condition involves subjective symptoms such as chronic pain.
4. Consistency with Plan Provisions and Prior Decisions: Another point of analysis was whether Lincoln Life’s decision was consistent with other provisions of the plan and with its prior decisions regarding Pifer’s disability claims. The court noted that Lincoln Life had approved Pifer’s claims for several years based on similar evidence, raising questions about the rationale for the sudden denial in 2021 without significant changes in her medical condition.
5. Procedural Fairness: The court examined the procedural aspects of Lincoln Life’s decision-making process, assessing whether the process was both reasoned and principled. Concerns were raised about the adequacy of the review process, particularly whether the FCE and subsequent reviews were thorough and unbiased.
6. Potential conflict of interest: Although not heavily emphasized, the Court also considered the potential for a conflict of interest given Lincoln Life’s dual role as both an evaluator and a payer of benefits. This factor was considered in light of the overall fairness and impartiality of the review process.

Ultimately, the court found that there were sufficient inconsistencies and potential oversights in the review process to warrant a remand. The court ordered Lincoln Life to reevaluate Pifer’s claim, taking into account all relevant medical evidence and the historical context of her disability approvals. The decision underscores the need for disability plan administrators to conduct thorough, fair, and unbiased evaluations of claims, especially those involving conditions with subjective symptoms such as chronic pain.

For individuals facing similar challenges with their disability insurance claims, it’s critical to have strong legal representation that understands the intricacies of ERISA and disability law. If you are struggling with a disability claim denial and need guidance, consider contacting the Ortiz Law Firm. With extensive experience helping claimants recover denied disability benefits, Nick Ortiz and his team can provide the expertise necessary to challenge unjust denials and advocate for your rights. You can contact us online or call (888) 321-8131 for a free case evaluation.

Disclaimer: This case was not handled by the Ortiz Law Firm. The court case is summarized here to give readers a better understanding of how Federal Courts decide long-term disability ERISA claims.

Here is a PDF copy of the decision: Pifer v. Lincoln