Denial of claim based on paper review reports and mischaracterization of occupation.

Christel R.

Christel R. worked as a computer analyst for large company. Her problems started many years before her disability, when she sustained a neck injury on the job, causing damage between C3-C4. She only missed one day of work but she was working in pain and simply endured it. As time went on she had increasing problems with her neck, as well as degenerative problems resulting from four herniated discs, spondylosis and stenosis of the spine. She continued to see the same orthopedic surgeon for these problems for more than a 10-year period and was treated with various conservative modalities. Her doctors recommended surgical fusion to stabilize her neck, but she opted to hold-off on surgery because she didn’t want to take the time off from work that would be necessary for recovery. Eventually the discs from C3-to C7 became involved and her doctor told her she was no longer a candidate for surgery as it would require too much disc fusion. Her pain gradually progressed. She suffered severe chronic pain that she tried to manage by taking on average 3200 mg of Motrin per day. She also experienced numbness in her hands and headaches. She underwent epidural injections to manage the pain. She eventually left work and was never able to resume the duties of her own occupation after that date. The medical and vocational evidence in support of her claim was substantial.

She submitted a Long Term Disability claim to the insurer, which it denied. The denial was based on a review by the insurer’s in-house “Vocational Rehabilitation Counselor”, who simply looked at Christel’s job description and classified her occupation as a “light strength”. This vocational “analysis” did not address the duties of her occupation that did not involve “strength”. However, this vocational review was relied upon again and again by the insurer and would serve as the foundation for all of its denials of her LTD claim.

A claim file note indicated the file was “triaged” by a nurse consultant, a vocational consultant and a team leader. It was suggested that the file be reviewed by the insurer’s “Medical Director” to provide his opinion as to whether Christel’s restrictions and limitations, “would preclude the ability to perform a light duty occupation”. From that point forward, all of the insurer’s claims and medical review decisions would rest upon this mischaracterization of her occupation as “light duty”, despite the fact that no competent vocational evidence supported it.

The “Medical Director” reviewed the file and without ever once laying eyes on Christel., concluded that she had “relatively minor spondylosis” and had “maintained neurologic function to the extent that she should not be precluded from continuing to work in at least a sedentary or light occupation.”

A claims representative simply parroted “Medical Director’s” conclusions, verbatim. The stated grounds for the denial were that: “there is no indication that you are demonstrating objective evidence of impairment of a degree that would prevent you from performing the material duties of your own occupation, which is of a light nature.”

An administrative appeal was taken. The insurer had an additional paper review doctor look at the file, who opined that there was “no documentation or substantiation of an orthopedic / musculoskeletal condition or entity which supports (Christel’s) statements that she unable to engage in full time work activities in the sedentary-light work category.” The insurer upheld the denial on appeal.

A second administrative appeal was then taken. A comprehensive vocational assessment and report was submitted with the appeal. That report established that Christel’s occupation was a hands-on position, requiring that she travel regularly to 38 company sites for the installation and repair of elements of the company telephone and computer networks. She spent many hours per week keyboarding while using a laptop computer both at her headquarters office and in the field; this activity required frequent reaching, handling and fingering. She often worked more than 40 hours per week. It was the stated opinion of the vocational expert that the insurer had misclassified Christel’s occupation. According to the expert, her “occupation was not light duty. While Christel's job included the responsibilities of Data Communications Analyst, as stated by (the insurer), her duties were broader. . . . Her combined responsibilities required Medium, not light, exertion.”

The insurer then had yet a third paper review doctor look at the file, who opined that “Impairment Conclusion: . . . Based on the provided documentation, the records fail to support a functional impairment that precludes work . . .. Rationale: In spite of the claimant's subjective complaints; her physical examination findings and MRI findings do not demonstrate a pathologic condition that would preclude light duty work. . .”

All of the paper reviewing doctors completely ignored the findings and conclusions of Christel’s treating doctors, as well as the report of an independent examining orthopedic surgeon. The medical reports were further based on objective clinical findings. The vocational work up and report was likewise ignored.

Result: A lawsuit was filed. The case was resolved satisfactorily.

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