Sometimes the biggest problem with a disability claim is the reluctance of treating physicians to become involved in the process. In a disability claim, the deck is already stacked against you. The insurance company has access to an endless parade of consulting doctors willing to say that there is insufficient evidence of your disability. To effectively refute these opinions, it is critically important for your doctors to advocate directly and forcefully on behalf of your claim.
Meanwhile, doctors don’t go to medical school because they want tp deal with burdensome and repetitive insurance company requests. They generally get into their profession to treat patients. Treating physicians often become frustrated with the disability claim process. Many simply disengage. Unfortunately, the treater’s refusal to advocate for their patients is one of the most common causes of claim denials and terminations.
One of the practical challenges Robinson Warncke has learned to overcome is how to deal with these reluctant treating doctors. We always acknowledge their frustration and do everything in our power to lessen the intrusions on their time. We always make sure the treating physician is not working outside his or her comfort zone. Many do not feel comfortable estimating a patient’s work capacity. We therefore strive to provide testing and measurements that give the doctor a firmer foundation, such as functional capacity evaluations for physically-based disabilities, or neuropsychological testing for cognitive disabilities.
In this case, Robinson Warncke represented an employment attorney working in the corporate office of a large national chain of restaurants. The client had been diagnosed with Rheumatoid Arthritis (RA) in her late twenties. Her RA remained controlled for many years, but eventually began to spiral out of control. Over a period of several years, the client suffered increasing damage to various joints, compounded by progressive spinal degeneration and back pain requiring significant surgery.
When the insurance company called on her treating rheumatologist to identify her physical restrictions and limitations (how many hours per day she could sit, stand, or walk, how much weight she could lift/carry, etc.), the rheumatologist declined to comment. The insurer then denied our client’s claim for long-term disability benefits.
RW was able to successfully appeal the denial of benefits by providing objective medical evidence and by obtaining a written statement from our client’s new rheumatologist. However, this case demonstrates the importance of having a treating physician willing to get involved when your disability insurer is disputing the validity of your claim for benefits.
Background and Claim History
Our client was diagnosed with RA when she was 27 years old. RA is an inflammatory disease in which the immune system attacks the patient’s own joints, causing damage to them and resulting in chronic pain, swelling and stiffness. The signs and symptoms of RA may include:
- Tender, warm, swollen joints
- Joint stiffness that is usually worse in the mornings and after inactivity
- Fatigue, fever and loss of appetite
Early rheumatoid arthritis tends to affect the smaller joints first — particularly the joints that attach the fingers to the hands and the toes to the feet. As the disease progresses, symptoms often spread to the wrists, knees, ankles, elbows, hips and shoulders. In most cases, symptoms occur in the same joints on both sides of the body. Often the most debilitating symptom of RA is crushing fatigue.
RA is typically treated using disease-modifying antirheumatic drugs (DMARDs). However, when that doesn’t work, rheumatologists may use biologics, genetically engineered proteins which block specific parts of the immune system that play a key role in inflammation of rheumatoid arthritis.
For many years, our client’s RA was successfully controlled using DMARDs. However, over time, the drugs became less and less effective and her symptoms progressively worsened. At approximately age 40, our client began receiving treatment with biologics in addition to DMARDs. Unfortunately, it was immediately apparent that our client’s RA was resistant to treatment with biologics. She attempted numerous injectable biologics without success, during which time she suffered significant flares of inflammation and disease progression. She also developed problems with her vision related to RA that were eventually controlled using an immunosuppressive eyedrop. Eventually, she was able to obtain adequate control over her RA using an intravenously (IV) administered biologic. During the time her RA was uncontrolled, however, she had already suffered significant damage to her larger joints, making it impossible to continue being as physically active as she was before.
Meanwhile, the condition of our client’s spine was also progressively degenerating, causing her severe low back pain with sciatica / radicular pain and muscle spasms. After initial pain management treatments failed to alleviate her pain, she was advised she should undergo lumbar fusion surgery and laminectomy. Laminectomy is a procedure wherein the lamina and spinous process of the selected vertebrae are removed to decompress the spinal canal and reduce pressure on the nerves. Fusion, meanwhile, is a procedure wherein two or more vertebrae are permanently fused. A bone graft material is placed along the targeted vertebrae that allows the patient’s own bones to grow and fuse the vertebrae together. During the fusion process, which typically takes 1 to 3 months after surgery, the vertebrae are immobilized using metal plates, screws or rods.
Despite her severe back pain and painful radiculopathy, our client put off having back surgery because of her RA. One of the major complications of RA is that patients must discontinue their DMARDs and biologics (which are both immunosuppressants, and thus interfere with healing) while undergoing and recovering from surgery. Because our client’s RA was already out of control, she did not wish to undergo surgery and cause her RA to worsen even more. She elected to pursue non-surgical options for as long as possible. She diligently pursued pain management treatment (epidurals, muscle relaxers, pain medication), chiropractic treatment, physical therapy, and exercise. However, over time her back pain became so severe that it was preventing her from being able to work as an attorney. She ultimately decided to move forward with scheduling the lumbar fusion and laminectomy surgery.
As an additional complication, our client’s rheumatologist had repeated problems during the time leading up to surgery getting her IV biologics approved by insurance in a timely manner, resulting in our client missing doses, exacerbating her RA symptoms. Our client decided to change doctors to a new rheumatologist whose office was better able to obtain approval for her treatments.
At the time of her back surgery, our client filed a claim for disability benefits with her insurer, CIGNA, and her claim was approved.
After undergoing this extensive and invasive surgery, our client had a very slow and painful recovery due to recurrent infection. This meant that she went without her RA drugs for more than 3 months, leading to a severe progression of her disease. By the time she was able to restart on her RA drugs, the IV biologics were no longer effective at controlling her symptoms and she was left in a near-constant state of RA “flare.” Making matters worse, her back surgery did not alleviate her back pain. While the surgery was technically a success, insofar as it achieved a solid fusion, she continued to suffer severe pain and was diagnosed with “post-laminectomy syndrome.” Due to RA and her back problems, our client was in severe pain and had very limited mobility due to joint stiffness, swelling, and fatigue. She was able to move around most days only with the use of a motorized wheelchair because her hands were too weak and painful to maneuver a manual chair.
Adding to our client’s health issues was the fact that her large joints had been damaged so much by RA that it was recommended she undergo multiple surgeries, including total joint replacements in the shoulder and knee. However, with her RA completely out of control after spine surgery, she could not undergo those surgeries and continued to suffer severe pain and immobility.
In short, our client was in a much worse condition in the year following her spine surgery than she had ever been before. Her RA was still uncontrolled, causing significant pain and joint stiffness and crushing fatigue, her back pain was still excruciating, and she had multiple invasive joint surgeries that were being put off due to her RA. Despite the obvious severity of her conditions, CIGNA reviewed her disability claim and terminated her benefits, finding that she could return to work full-time as an attorney.
Our biggest question when we took on the case was how this could have happened. How could someone who is in such bad shape and who is so clearly disabled have their benefits terminated? In reviewing the claim file, it turned out the answer was that our client’s physicians had been less forceful than necessary in responding to CIGNA’s requests. CIGNA had taken advantage of that to find her not disabled.
CIGNA’s denial letter relied entirely on a paper-only review from a consulting physician who opined that our client could sit full-time without restrictions and that her RA symptoms would not prevent her from working.
RW Successfully Appeals CIGNA’s Termination of Benefits
When RW took on the case, our first action was to review CIGNA’s claim file to see where the train had left the tracks for this claim. This is when we learned that the issue leading to termination of benefits was a combination of poor advocacy by our client’s treating physicians and a less-than-thorough claim investigation by CIGNA.
CIGNA had sent letters to her treating physicians and asked them about her physical restrictions and limitations. CIGNA invited the doctors to fill out a form specifying physical restrictions and limitations. Several of our client’s physicians declined to respond at all, and the ones that did respond were not treating her disabling conditions, so they had nothing to offer.
Her rheumatologist responded to CIGNA’s inquiry by recommending a Functional Capacity Evaluation (FCE). An FCE is widely considered the “gold standard” test for establishing physical work restrictions. It consists of a series of tests performed by a licensed physical therapist, using objective measurements and comparing the results to normative data. The FCE also contains various embedded measures of effort and validity to ensure that the patient gives their full effort on all testing. This is necessary to confirming a reliable measurement of the patient’s level of functioning.
CIGNA did not follow the rheumatologist’s recommendation. In fact, the claim file revealed that CIGNA’s claims personnel had gone out of their way to avoid the rheumatologist’s suggestion.
Our file review also confirmed that the CIGNA’s medical consultant review was deeply flawed, as is often the case with hired gun reviews. In our appeal, RW pointed out the flaws in CIGNA’s review, noting that its orthopedist was not an appropriate doctor to review a claim involving a complex autoimmune disorder. Moreover, his report was vague and conclusory, ignoring some of the most important evidence regarding RA severity.
We also arranged for our client to undergo the Functional Capacity Evaluation (FCE) her rheumatologist had suggested before CIGNA terminated her benefits. The FCE objectively found our client was not capable of performing even sedentary-level work.
Thankfully, that rheumatologist was also more willing to involve himself in the disability appeal process, largely because we had arranged the objective testing he wanted in the first place. RW interviewed the rheumatologist and provided a transcript of the interview to CIGNA. Among other things, the rheumatologist told RW that our client had a very aggressive type of RA that was multi-drug resistant. He further explained that RA treatment is designed to slow down or control the progression of the disease, but that it doesn’t reverse the damage already done. He also discussed our client’s crushing fatigue in significant detail, agreeing that it would prevent her from working full-time in any type of job.
RW submitted the administrative appeal, including the FCE report, the rheumatologist’s interview transcript, additional medical records, and detailed statements from our client and witnesses. Within a matter of a couple months, CIGNA reversed its decision to terminate benefits, finding our client likely permanently disabled from performing any sedentary work on a full-time basis. Our client was able to go back to focusing on what was important: her treatment. This was another satisfying win for RW. Our client was clearly disabled, and she simply needed RW’s assistance in getting her insurer to accept that fact.
As this case should make clear, having a treating physician on your side against your disability insurer is often critical to the success of the claim. Many doctors don’t seem to understand that their support can make or break a claim for disability benefits. Some just flatly refuse to be bothered to comment on a disability claim. If you have reason to believe that your physician is unwilling to help you with your claim, you should have a serious and frank discussion with the doctor about it. If the doctor continues to be uncooperative, you should seriously consider changing providers, if possible. It could be the difference between recovering disability benefits and having no source of income.