As some of our Bay Area ERISA clients have experienced, multiple sclerosis (MS) can be a severely incapacitating condition. The Mayo Clinic describes MS as a potentially disabling disease of the brain and spinal cord. The immune system attacks the myelin that covers nerve fibers and causes communication problems between the brain and the rest of your body. In MS, the nerves may deteriorate or become permanently injured. The signs and symptoms of MS vary depending on the amount of nerve damage and which nerves are affected. People with severe MS may lose the ability to walk on their own, while others may experience long periods of remission without any new symptoms. If your MS becomes severe, you may no longer be able work. Because not all people with MS suffer from symptoms that interfere with work, a diagnosis of multiple sclerosis alone is not enough to get your long term disability insurance claim approved.
A couple of recent case decisions illustrate the difficulties faced by people with MS who are trying to obtain benefits from their employer-provided disability plan. For example, in Burell v. Prudential Ins. Co. of Am., 820 F.3d 132 (5th Cir. 2016), Prudential Insurance Company of America denied Burell’s long term disability benefits because it determined that his MS did not render him unable to perform the material and substantial duties of his regular occupation. Although Burell claimed he was entitled to benefits because he could not work, Prudential’s hired “independent” doctors concluded that he had no physical or cognitive impairments caused by MS. After losing at the district court level, Burell appealed to the Fifth Circuit Court of Appeals. But, the Court of Appeals ruled against him. The Court found that although Burell’s diagnosis of MS was not seriously in dispute, “a diagnosis of MS is not sufficient on its own for Burell to qualify for long term disability benefits under the Plan.” Id. at 139. The Court was satisfied that none of the health care providers consulted by Prudential found that Burell had physical or cognitive impairments. It relied on doctors who never evaluated Burell in person.
In Slaton v. Standard Ins. Co., No. 3:14-CV-269, 2016 WL 316864 (S.D. Ohio Jan. 26, 2016), Slaton worked as an attorney before he became disabled by MS, which was diagnosed by an MRI and a spinal tap. His neurologist strongly supported his claim of disability. Standard Insurance Company denied Slaton’s claim by relying on a medical record review by a physician who did not examine Slaton in person. Standard’s doctor questioned the number of oligoclonal bands found in the MRI that supported the diagnosis of multiple sclerosis. Slaton’s doctor offered a strong rebuttal. He explained that 70 percent of individuals with multiple sclerosis start with “intermittent flare ups of neurologic symptoms, usually in the form of physical deficits,” but that cognitive impairment “occurs in up to half of all multiple sclerosis patients early in the disease,” impacting their “ability to function on a day-to-day basis.” He indicated that there can be a “slow accumulation of neurological dysfunction.” Id. at *3. Ultimately, Standard concluded that the medical documentation did not support limitations or restrictions that prevented him from performing with reasonable continuity the material duties of his own occupation. The court affirmed Standard’s decision and its requirement that Slaton’s claim be supported by “objective medical evidence.” There was no evidence in this case that Slaton’s MS was clinically active.
In sum, it is not enough to get disability benefits by demonstrating an MS diagnosis or getting a note from your doctor. Our firm has many years of experience demonstrating how one’s medical condition impacts his or her functionality. Specifically, we have helped clients with MS obtain short term and long term disability benefits when their disease has become disabling. If you have multiple sclerosis and need help filing a disability insurance claim or an appeal of a denied claim, you should contact an experienced insurance attorney right away.