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Erisa: Bar Objective Evidence Requirement

September 02, 2016

Posted in Bad Faith Insurance

In ERISA claims, disability insurance companies often state in their denial letters that the insured does not qualify for benefits because he has not stated “objective evidence” of disability. However, case law in the 9th Circuit and elsewhere is clear that an ERISA insurer cannot properly insist on proof with “objective evidence” if the condition is one for which objective evidence is unlikely to exist.

“[C]onditioning an award on the existence of evidence that cannot exist is arbitrary and capricious.” Salomaa v. Honda Long Term Disability Plan, 642 F.3d 666, 678 (9th Cir. 2011). In the 11th Circuit, the Court of Appeals stated: “Many medical conditions depend for their diagnosis on patient reports of pain or other symptoms, and some cannot be objectively established” but “a disability insurer [cannot] condition coverage on proof by objective indicators . . . where the condition is recognized yet no such proof is possible.” Id. The United States Court of Appeals for the Eleventh Circuit has observed, “There is, quite simply, no laboratory [ ] test to diagnose chronic pain syndrome. . . . Chronic pain syndrome is a severely debilitating medical condition that may be fully diagnosed only through long-term clinical observation . . . .” Lee v. BellSouth Telecomms., Inc., 318 F. App’x 829, 837 (11th Cir. 2009).”

In Palmer v. University Medical Group, 994 F. Supp. 1221 (D. Or. 1998) in which the insurer denied benefits on the ground, in part, that the insured’s back injury symptoms were all “subjective” and not confirmed by X-Ray or MRI, the court reversed the ERISA insurer’s denial. In reversing the denial and ordering he payment of benefits, the court stressed that, absent solid proof that the “subjective” symptoms were not genuine, the denial was improper. As the Palmer Court stated:

“Throughout the claims review process, Standard’s overriding concern was “objective medical evidence” While that certainly is a relevant consideration, Standard erred in this instance by elevating it to an absolute pre-requisite. Not all medical conditions as readily susceptible to verification by x-rays or other laboratory tests. Some complaints — such are pain and fatigue — are difficult to objectively measure, and there is considerable variation among individuals. See Bunell v. Sullivan, 947 F.2d 341, 345-47 (9th Cir. 1991) (en banc). There also is much that we do not know about the human body. Merely because we cannot see pain or fatigue on an x-ray, or measure it in a laboratory, does not mean that it is not real. CF, Bunell, 947 F.2d at 347 (“We cannot conclude that Congress intended to require objective medical evidence to fully corroborate the severity of pain while aware of the inability of medical science to provide such evidence.”)”

(Emphasis Added.) (Id. at 1233.)

If you received a denial of benefits based on the absence of “objective evidence,” chances are high that the insurer’s denial is arbitrary and capricious. In fact, a denial based on the purported lack of “objective evidence” is one that usually betrays a biased and unfair evaluation.

Contact The Law Offices of Bennet M. Cohen, P.C. to arrange a consultation with an experienced San Francisco, CA denials governed by ERISA attorney.

The post

In Many ERISA Cases, The Disability Insurer Should Be Barred From Requiring “Objective Evidence” Of Disability

appeared first on San Francisco Top Disability Attorney and Insurance Claim Denial Law Firm.

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