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Diagnosis is Not Always Sufficient to Establish a Disability

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On January 26th, 2017, the United States District Court for the District of Nevada issued an instructive decision in the case of Decovich v. Venetian Casino Resort, LLC. This case reiterates a very important point that disability claimants must know: A mere diagnosis is not, by itself, enough to actually obtain disability benefits. Here, our ERISA litigation lawyers highlight some key details of the case.

The Background of the Lawsuit

Ms. Decovich was employed full-time as a card dealer at Venetian Casino in Las Vegas. In late 2008, her doctor diagnosed her with fibromyalgia. The Mayo Clinic describes fibromyalgia as a medical condition that results in widespread and chronic pain. By September of 2009, Ms. Decovich stopped working completely due to the fact that her fibromyalgia had become disabling. In January of 2010, she filed her claim for long-term disability benefits. When reviewing her claim, the insurance company obtained the medical records from her doctor, a standard practice. However, when the insurer accessed these records, they noted that while her doctor did diagnose her with fibromyalgia, he did not actually include any restrictions or job-related limitations.

Why the Court Denied Disability Benefits

The court accepted the fact that Ms. Decovich did have a valid diagnosis of fibromyalgia. However, the court explicitly stated that a diagnosis is not the equivalent of a disability. In the eyes of the court, there was simply insufficient evidence contained within the Administrative Record to establish the fact that the plaintiff had a qualifying disability under her ERISA regulated policy. The court took strides to note that there was no evidence provided within the claim file that proved that Ms. Decovich could not perform essential job functions.

Getting Proper Documentation is Critical

The lesson from this decision is simple: Getting documentation that proves your inability to work is critically important. In this case, the Nevada District Court actually acknowledged that there was some minor evidence to suggest that  Ms. Decovich had an impairment. The court also accepted her diagnosis. However, the court, citing several precedential Ninth Circuit Court of Appeals cases, pointed out that an individual must be able to use the information contained within her claim file to prove that her condition actually prevents her from performing essential job functions. Ms. Decovich simply could not meet that standard. This case demonstrates why it is so important to get an attorney by your side as soon as you receive an initial disability denial letter. Our attorneys work aggressively from day one to ensure that you have submitted the best available medical evidence to the insurance company.

Contact Our Office Today

At Kantor & Kantor LLP, our ERISA appeals lawyers have helped many individuals who have had their disability benefits wrongfully denied. To learn more about what our lawyers can do for you, please call us today at (510) 992-6130 to set up a no fee, no-obligation review of your case. We represent clients throughout Northern California, including in San Mateo County and Santa Clara County.

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