Published by The Pellegrin Firm December 17, 2019

In a recent decision dated December 4, 2019, a federal district court in Maryland returned a favorable decision for a claimant seeking long-term disability benefits for her fibromyalgia. The court found Boston Mutual Life Insurance Company was wrong to require objective evidence of fibromyalgia, when doing so is next to impossible for an afflicted patient. The court reviewed the case under the U.S. Court of Appeals for the Fourth Circuit’s somewhat deferential abuse of discretion standard for ERISA plans that grant a benefits administrator discretion to interpret a plan’s terms. Even so, the court found, the decision to deny benefits was unreasonable.

Fibromyalgia is a disorder characterized by widespread musculoskeletal pain. Doctors believe that fibromyalgia amplifies painful sensations by affecting the way a patient’s brain processes pain signals. By its very nature, it is difficult to provide objective evidence of the condition.

However, in the present case, the court found that the plaintiff/claimant’s complaints were sufficient for her doctors to give her the diagnosis, and the defendant insurer was unreasonable to require objective evidence for payment of benefits.

The court found that the claimant was entitled to benefits for the two-year regular occupation period in the LTD policy because she had shown she could not perform her regular occupation. In order to show entitlement to benefit beyond those two years, the claimant would have to show she could not perform any gainful occupation. The judge decided she could not decide eligibility for “any occupation” benefits on the record before her. The case is Krysztofiak V. Boston Mutual Life Insurance Co., 9-0879, 2019 WL 6528609 (D. Md. Dec. 4, 2019).