Download PDF If She Only Knew . . . : Patricia Jacobson’s Story of Fibromyalgia

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Editorial Reviews. About the Author. SUZANNE FITZPATRICK has written for several Television series including 7th Heaven and Divine Will. She has also.
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But it found that he is not among the minority of fibromyalgia sufferers who are totally disabled, even though Dr.

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Katz reported that Hawkins cannot sit or stand for more than a few minutes at a time. He needs frequent rest periods each hour.

Since this condition is chronic we do not anticipate a marked increase in functional level without increase in pain. Katz that Hawkins was not totally disabled. Each party makes a bad argument, and let us clear them out of the way. Hawkins argues that the plan was required to give greater weight to the opinion of the treating physician, Dr.

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Katz, than to the opinion of the consultant, Dr. Apfel, F. Chater, F. Massanari, F. Heckler, F. But such skepticism may have a stronger basis when the treating physician squares off against a neutral consultant appointed by the Social Security Administration than when the consultant is hired by the administrator of a private plan and so may have a financial incentive to be hard-nosed in his claims evaluation in order to protect the financial integrity of the plan and of the employer that funds it.

Ladd v. ITT Corp. See Bali v. Whitson v. Finch, F.

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The courts are divided on whether the presumption applies to benefits determinations by administrators of ERISA plans. Compare Nord v. Fortis Benefits Ins. Metropolitan Life Ins. Connecticut General Life Ins. Sara Lee Corp.

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We have not addressed the issue. See also Leahy v. Raytheon Co. Maybe the Supreme Court will resolve it in the Nord case. But the procedures followed by plan administrators are matters of contract. Bruch, U. Standard Ins. This would be correct were there a logical incompatibility between working full time and being disabled from working full time, but there is not.

A desperate person might force himself to work despite an illness that everyone agreed was totally disabling. Perlman v.

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Swiss Bank Corp. Comprehensive Disability Protection Plan, F. Chater, 64 F. Shalala, 21 F. Yet even a desperate person might not be able to maintain the necessary level of effort indefinitely.


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Hawkins may have forced himself to continue in his job for years despite severe pain and fatigue and finally have found it too much and given it up even though his condition had not worsened. A disabled person should not be punished for heroic efforts to work by being held to have forfeited his entitlement to disability benefits should he stop working. Katz reported. Obviously a Web designer works at a computer, but there is nothing in the answers to the questionnaire to indicate that Hawkins is sitting full time, as it were, or that he has any aspiration to be a full-time Web designer or for that matter an 80 percent of full-time Web designer.

If he does the latter, it does not prove that he is not disabled. We can imagine an argument that even if the activity disclosed in the questionnaire does not indicate a capacity to engage in full-time work, the fact that it is discrepant with the level of activity described by Dr.

June, 2013

But that argument is not made. That leaves the plan with only Dr. According to a personal activities questionnaire, … Mr. Hawkins reported that he was able to take classes and undergo pool therapy…. There are no objective findings to support restrictions. Hawkins has various subjective complaints, he has been able to perform various extracurricular activities, including pursuing further education. The diagnosis of fibromyalgia does not, in and of itself, produce permanent impairment.

Although Mr. Hawkins may report an increase in subjective pain complaints on a return to work, an inability to work within the guidelines … is not objectively supported in the medical records. The fact that the majority of individuals suffering from fibromyalgia can work is the weakest possible evidence that Hawkins can, especially since the size of the majority is not indicated; it could be The fact that he can undergo pool therapy says nothing about his condition, nor the fact, a variant of the first point, that the diagnosis of fibromyalgia does not in and of itself produce permanent impairment.

Obviously the diagnosis produces nothing, but one sees what Dr. Chou was driving at — and it is still irrelevant. But the gravest problem with Dr. Pain often and in the case of fibromyalgia cannot be detected by laboratory tests. Chou seems to believe, erroneously because it would mean that fibromyalgia could never be shown to be totally disabling, which the plan does not argue, that because it is subjective Hawkins is not disabled.

But the discretion is not unlimited. The record contains nothing more than scraps to offset the evidence presented by Hawkins and by Dr. The denial of the application was unreasonable. The judgment is reversed and the case remanded to the district court for further proceedings consistent with this opinion. And…here is some good news: sometimes you can use the contractual limitations defense even if the contractual limitations period was not disclosed in the denial letter. March 23, But she did not file her lawsuit until March 4, If you need help with your long-term disability case, call us.

Judge McKeague, who dissented from the original panel opinion, wrote the decision for the en banc court. The opinion generated a number of separate opinions. Pautler , Ruth Streit , Mark S. Weisberg and Patricia Winchell. Yesterday, in Heimeshoff v. Legal action cannot be taken against The Hartford. Absent a controlling statute to the contrary, a participant and a plan may agree by contract to a particular limitations period, even one that starts to run before the cause of action accrues, as long as the period is reasonable.

In light of Heimeshoff , plan sponsors who do not have similar provisions in their plans may wish to add such provisions. Here is why:. ERISA does not provide a limitations period for filing a lawsuit after a benefit claim has been denied. Courts generally apply the limitations period prescribed by state law for the action most analogous to the claim for benefits. But if the plan prescribes a time limit for the filing of a lawuit, the courts generally will enforce that time limit.

Thus, for example, if the plan terms require suit to be brought within one year, courts generally will enforce that one-year limitations period even if the applicable state law prescribes a longer period. Heimeshoff addressed the issue of whether the plan by its terms may prescribe when that plan-prescribed limitations period begins to run.

Generally, limitations begin to run when a cause of action accrues and courts generally have held that an ERISA cause of action does not accrue until the participant has exhausted his administrative remedies. The petitioner in Heimeshoff asserted that if she had not exhausted her administrative remedies so that her cause of action had not accrued and she could not file suit in court, it should not be permitted that the limitations period applicable to her claim already had begun to run.

The Supreme Court rejected this argument. In Heimeshoff, the claimant filed her claim for disability benefits in August In November Hartford advised that it could not determine whether she was disabled because her doctor had failed to provide requested additional information. In July and October the claimant provided additional information, but Hartford denied the claim in November In May the claimant asked for her time to file an administrative appeal be extended to September and Hartford granted that request.

On September 26, the claimant submitted her administrative appeal and Hartford denied that appeal November 26, The claimant argued that in some instances, her statute of limitations could run before she had even exhausted her administrative remedies. The Court suggested that provisions similar to those in Heimeshoff would work a hardship mainly on those who did not diligently pursue both the plan administrative appeals and judicial review. The claimant asserted that limitations should be tolled during administrative proceedings.


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  8. But the Supreme Court found that tolling is required under ERISA only if the plan offers voluntary internal appeals beyond what is permitted by regulation. In our experience, it has been easy for plan sponsors to prescribe a shortened limitations period that assures that once the administrator denies the administrative appeal, the participant promptly proceeds to court. In some instances it has been more difficult, however, to require a participant to file a prompt claim for benefits.

    Showing that prejudice can sometimes be a difficult challenge. The participant who delays two years filing his administrative claim may find that, upon the exhaustion of his administrative remedies, his limitations period already has expired. The content of this article is intended to provide a general guide to the subject matter. Specialist advice should be sought about your specific circumstances. One of the biggest problems you may encounter with making a long-term disability claim is the actual policy language versus the summary plan description. We are here to help you. If you are running into problems making your long term disability claim, call us today!