Will My Insurer Take Into Account My Subjective Symptoms? A Case Study
For many conditions common among dentists and physicians, there are symptoms that are subjective in nature and cannot always be proven up with an objective test. One example of this are pain levels—which, of course, can affect whether or not an individual is able to perform the substantial and material duties of his or her occupation. But will your insurance company take into account your reported symptoms when deciding whether to approve benefits? The answer is – not always.
One example of this is the case of Pifer v. Lincoln[1]. The Plaintiff, Rebecca Pifer, worked as a dental analyst for an insurance company when she was diagnosed with Ehlers Danlos Syndrome, with associated osteoarthritis involving the cervical spine, right shoulder, hands, and feet, as well as a right shoulder rotator cuff tear in 2011. Pifer filed a disability insurance claim, which Lincoln approved in 2012. They continued to pay her benefits from 2012 – 2020. In 2021, Lincoln terminated the claim after conducting surveillance, an interview with Pifer, and a functional capacity evaluation (FCE).
Pifer appealed this decision and submitted records from her treating physicians and physical therapy records, which indicated that, overall, her symptoms were worsening. Her physicians submitted APS forms confirming she was “permanently disabled.” Pifer also submitted a self-logged symptom journal. Despite this evidence, Lincoln upheld its denial and Pifer filed a lawsuit. In regards to the pain journal, Lincoln argued that the pain journal was subjective and “crafted for the specific purpose of supporting [Plaintiff’s] claim.” The Court, however, found that Lincoln had erred in not considering the journal—especially in not providing it to their reviewing physician.
While the pain journal was not the only evidence that supported Pifer’s limitations and her inability to return to work (including treatment records, statements from her physicians, and physical therapy records) that Lincoln or its experts did not adequately consider, it was a component. The Court explained that “[w]hile the Policy grants Defendant discretion in evaluating Plaintiff’s medical records, it does not permit Defendant to ignore a claimant’s subjective evaluation of her symptoms, particularly pain.”
Because they had failed to adequately consider all the evidence available to them, and because they could not demonstrate “any evidence that Plaintiff’s condition improved in a manner that warranted a reversal” of their decision to approve benefits for years, Pifer’s case was remanded back to Lincoln.
Pain journals can be important tools in documenting symptoms and severity, both in terms of reporting to your treating provider as well as to an insurance company. For example, your insurer may conduct an interview with you, where they specifically ask questions about your symptoms and their impact.
However, as the above case shows, insurance companies may try to discredit or ignore subjective reports of symptoms. If you feel your insurance company is ignoring evidence in support of your claim, please feel free to reach out to one of our attorneys directly.
Every claim is unique and the discussion above is only a limited summary of the court’s ruling in this case. If you are concerned that your insurer is not evaluating your claim under the proper standard, an experienced disability insurance attorney can help you assess the situation and determine what options, if any, are available.
[1] Pifer v. Lincoln Life Assurance Co. of Bos., No. 1:22-CV-186, 2023 WL 5208111 (M.D.N.C. Aug. 14, 2023)
