Disability insurance plan participants in the Midwest and Chicago may be surprised to learn that a person with cancer claiming disability benefits through an employer’s plan would have trouble obtaining the benefits. Why would anybody with such a debilitating condition receive a denial from a plan administrator for disability benefits? Disability plan administrators are much like high school geometry teachers grading proofs. They look for a step-by-step connection between the condition and the inability to work.
Individuals with cancer often develop other illnesses, conditions or syndromes collateral to the cancer itself that contribute to the disability. Sometimes that collateral condition is what makes the connection between the cancer and the inability to work. Disability plan administrators look primarily for objective record evidence of the limitation or restriction that causes a claimant to not be able to work. Absent such clear and objective evidence, the administrators will often deny the claim for benefits. Even if such a connection is made, administrators may still deny the claim, but a claimant is then better positioned to challenge the decision in court.
A recent claimant had to do just that in Spina v. CVS Long Term Disability, 2011 U.S. Dist. LEXIS 26311 (S.D. Ohio Mar. 2, 2006). Ms. Spina had stomach cancer, and underwent subtotal gastrectomy which removed 75% of her stomach, and attaching the remaining portion of the stomach directly to the small intestine. After surgery, Ms. Spina had several complications, involving several additional surgeries. After all surgeries, she completed courses of radiation and chemotherapy. Following the surgeries, Ms. Spina developed Dumping Syndrome because of the reduction in size of her stomach and its direct attachment to the small intestine. Because of the speed with which food Spina ingested would enter her small intestine, she developed severe diarrhea after meals. Spina also had to eat many small meals a day because of her reduced stomach size, and so her personal statement (submitted by video in this case) described her limitation because of the amount of time she spent in the washroom daily.
The physicians the plan retained to review the file concluded Spina was not disabled. The first physician opined the dumping syndrome was not “severe” enough because Spina had never been hospitalized for her diarrhea. The Court disagreed that one must be hospitalized from the effects of dumping syndrome in order for it to be severe. She also erred by opining that though the treating physician prescribed dietary modifications and medication, there was no evidence those orders were controlling the condition.
The plan administrator, Hartford Life and Accident Insurance Company, discounted Spina’s video statement describing her condition because she had earlier told a doctor the dumping syndrome did not bother her too much when she was at home. The court, however, noted that Spina’s ability to cope with the syndrome at home was not in issue–her ability to cope with it at work was. Also, the record did not demonstrate that there were any jobs that could accommodate the level of washroom use Spina required.
This was a classic case of the plan administrator looking to the absence of test results to prove an inability to work where common sense clearly showed an individual cannot go to work with the limitations the dumping syndrome imposed on Spina. If you have an illness, condition or syndrome that you believe qualifies you for benefits under your employer’s disability plan, speak to an experienced ERISA lawyer.