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Labor & Employment – ERISA – Long-Term Disability Benefits – Subjective Pain Complaints – Objective Diagnoses

Labor & Employment – ERISA – Long-Term Disability Benefits – Subjective Pain Complaints – Objective Diagnoses

DuPerry v. Life Ins. Co. of North America. (Lawyers Weekly No. 11-01-0110, 29 pp.) (Traxler, J.) No. 10-1089, Jan. 24, 2011; USDC at New Bern (Flanagan, Ch.J.) 4th Cir. Click here for the full text of the opinion.

Holding: A former payroll and benefits clerk whose work ethic was “unsurpassed,” according to her employer, is entitled to long-term disability benefits under the employer’s ERISA benefits plan for her inability to work due to disabling fibromyalgia, rheumatoid arthritis and osteoarthritis; the 4th Circuit says denial of benefits was an abuse of discretion and it upholds the district court’s decision to award claimant benefits and attorney’s fees.

Under the abuse-of-discretion standard, the reviewing court will set aside the plan administrator’s decision only if it is not reasonable. The factors discussed in Booth v. Wal-Mart Stores Inc. Associates Health & Welfare Plan, 210 F.3d 335 (4th Cir. 2000), continue to guide our abuse-of-discretion review under ERISA.

Claimant’s case turned on the question of whether she was in fact unable to perform the material duties of her job.

Considering all the evidence together, we simply see no reasonable basis in the record for defendant’s denial of this claim. It is undisputed that claimant suffers from chronic diseases that are potentially debilitating. She has presented substantial evidence from her physicians that these diseases do, in fact, prevent her from working. And she has presented her own declaration and declarations from her family and even her former employer confirming the severity of her symptoms.

The only evidence of any consequence that defendant can point to as conflicting with claimant’s entitlement to benefits are the reports of Dr. Levesque. However, these reports contain no significant basis supporting a conclusion that the symptoms from claimant’s fibromyalgia, either by themselves or combined with the symptoms from her other conditions, are not sufficiently severe as to prevent her from enduring the rigors of her workweek.

Especially in light of the structural conflict present here by virtue of defendant’s dual role as insurer and administrator of the plan, we conclude defendant’s denial of the claim was unreasonable and an abuse of discretion.

Defendant also contends the district court erred in importing a Social Security disability income rule into the ERISA arena.

Even assuming that subjective complaints cannot be sufficient by themselves to support a disability benefits claim, that is not what we have here because claimant’s subjective complaints were only part of the evidence of her condition. The existence of objective evidence that she suffered from rheumatoid arthritis, osteoarthritis and fibromyalgia is not disputed. That a person with these diseases would suffer significant pain and fatigue is also well established.

Claimant’s subjective complaints served only to pinpoint the precise intensity of her symptoms and her inability to endure them over the course of a workweek. In the absence of any significant basis for rejecting the account of claimant and her treating physicians and in light of the structural conflict of interest that defendant faced as the result of its dual role as administrator and insurer, defendant’s denial of benefits constituted an abuse of discretion.

We believe this is one of those rare cases where a remand to the plan administrator would serve no purpose. Under the circumstances of this case, we hold that the district court was within its discretion in awarding claimant benefits up to the date of its decision in lieu of remanding to the plan administrator.

Judgment for claimant affirmed.


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