Dana Krysztofiak (“Krysztofiak”) works as a registered nurse but was previously a Clinical Coordination Manager for the company HomeCare Maryland, LLC. In 2016, Krysztofiak ceased working because of problems with fibromyalgia and psoriatic arthritis. She then filed for long term disability benefits with Boston Mutual Life Insurance Co. (“Boston Mutual”). According to the language of the policy:
“Disability means that due to sickness or injury;
- You are not able to perform one or more duties (with reasonable continuity) or each and every duty of your regular occupation and you have at least a 20% loss in your pre-disability earnings.
- While you are not able to perform one or more duties (with reasonable continuity) or each and every duty of your regular occupation, you are working in any occupation and have at least a 20% loss in your pre-disability earnings.”
Further, payments only extend beyond 24 months if a person cannot perform each and every duty of any occupation, or if unable to perform each and every duty of her own occupation, she is able to work in any occupation but has a minimum of a 20% decrease in pre-disability earnings.
By April 13, 2017, Krysztofiak had begun receiving monthly payments of $4,377.50 from Boston Mutual. The following year, Boston Mutual determined that Krysztofiak was not disabled anymore and ceased her benefits on May 29, 2018. Krysztofiak appealed through an administrative process but this was also denied on March 20, 2019. The instant suit followed on March 25, 2019.
Prior to the termination of Krysztofiak’s benefits, her treating physician, Dr. Tazeen Rehman opined that her disability was no longer due to psoriatic arthritis and that “[h]er limitations are due to fibromyalgia.” Boston Mutual stated that because Krysztofiak’s psoriatic arthritis was under control, she no longer met the definition of disability simply based on her fibromyalgia.
During the review process, Boston Mutual had its claims administrator, Disability Reinsurance Management Services, Inc. (“DRMS”) perform a functional capacity evaluation (“FCE”) on Krysztofiak. While taking part in the process, she “refused Floor to Waist and Waist to Shoulder lifts, and carry task” and “refused to try filing, typing and assembly tasks.” The administrator of the test specifically took note of the fact that he was “unable to determine her physical demand level” because “[d]uring various components of the evaluation, claimant demonstrated lack of effort.”
However, regardless of Krysztofiak’s apparent unwillingness to participate, the results of the functional capacity evaluation stated that “[b]ased on the results of this evaluation, claimant would not be able to perform the job functions of Clinical Coordinator Manager, due to claimant not being able to perform frequent fingering, modifications required with walking, sitting limitations, and not being able to demonstrate productive functional reach pattern.” The results also indicated that Krysztofiak needed “positional changes on both days (sit to supine), which would make it difficult for claimant to perform modified or light duty work.”
Because the functional capacity evaluation’s results were inconsistent, Boston Mutual had a Dr. John Parkerson examine Krysztofiak in person. He opined that “A diagnosis of fibromyalgia does not present her with any physical limitations or restrictions.” In addition, Krysztofiak’s own doctors both stated that she had fibromyalgia which caused specific limitations. Lastly, DRMS had Dr. Stewart Russell review Krysztofiak’s medical records, who then concluded that “the insured likely has fibromylgia” but found “no support for an inability to perform at least a minimum of full-time sedentary activity[,]” and that “self-reports of the insured are not consistent with the overall medical information.” Dr. Russell also indicated that Krysztofiak had been prescribed opioids and that those were inappropriate for a patient with fibromyalgia and that “[i]nsured has never been in an appropriate treatment for fibromyalgia.”
Here, Boston Mutual alleges that Krysztofiak has not provided “objective evidence” of her limitations, therefore she has failed to prove that she has a disability. Alternatively, Krysztofiak argues that Boston Mutual made a decision without substantial evidence that was not reasoned or deliberate, not consistent with previous decisions to grant benefits, and the product of a conflict of interest.
Upon review, the court specifically pointed to Dr. Russell’s indication that “[s]ince fibromyalgia is not a condition that demonstrates destruction of any tissue in the body, there is no support for an inability to perform at least a minimum of full-time sedentary activity.” More particularly, the court explained that this meant fibromyalgia could not, under any circumstances, meet the definition of disability in the policy. The court then went on to cite several cases which explained that “an FCE is a highly questionable tool for determining whether a fibromyalgia patient is disabled.”
The court further cited the DuPerry case, wherein the insured “produced the only types of evidence a claimant in her situation could produce, her own description of her subjective symptoms, videos showing how she moved in her condition, and her treating physician’s opinion that the pain and fatigue rendered her unable to work.” The court determined that Krysztofiak has done the same in this case.
Boston Mutual also attempted to show that because Krysztofiak received opioids, that she had inappropriate treatment and was therefor disqualified for receipt of benefits. However, the court found that DRMS’s denial of Krysztofiak’s appeal did not mention the inappropriate treatment as its basis for denial. The denial was, instead, based on the belief that Krysztofiak was able to perform the duties of her job as a Clinical Coordination Manager.
Lastly, the court chose to dismiss the idea that Boston Mutual, as both claims administrator and payor, was a decisive conflict of interest in this case. At this point, the court determined that Krysztofiak was entitled to the payment of long term disability benefits under the policy issued by Boston Mutual. The court, however, limited its ruling to apply to benefits accrued during the first twenty-four months of disability. Therefore, the court ruled in favor of Krysztofiak and against Boston Mutual, granting her motion and denying its motion.[Note: this claim was not handled by the Ortiz Law Firm. It is merely summarized here for a better understanding of how Federal Courts are handling long term disability insurance claims.]
Here is a copy of the decision in PDF: