| As an employee of Countrywide Home Loans, Inc., | | | | determined that Sacks was no more likely to fall at |
| Lynda Sacks participated in both the short-term and | | | | work and at home, and could see no reason why she |
| long-term disability plans her employer provided. | | | | would be less capable of handling her sedentary job |
| Countrywide contracted with Standard Insurance | | | | that previously. |
| Company to fund both disability plans and make the | | | | Information is Not Considered Adequate by |
| claims decisions. Sacks disability plans became | | | | Standard's Benefit Review Department |
| effective January 1, 2005. | | | | Based on these findings Standards Benefits Review |
| Disability Insurance Plan Requires Inability to Perform | | | | Department upheld the denial of Sacks' claim. She |
| Duties of Own Occupation | | | | appealed again. In an October 18 conversation with a |
| Sack's employment was as an underwriter at | | | | Standard representative, Sacks was told that she |
| Countrywide Home Loans. The routine duties of her | | | | needed to provide additional medical information. She |
| job included approving and denying mortgage loans, | | | | told the representative that all of her doctors were |
| reviewing and evaluating the information on the | | | | with Kaiser. Sacks' husband sent Standard an e-mail |
| mortgage loan documents and assembling documents | | | | on October 19 to notified them that they had been |
| into the loan file. The job was primarily sedentary, | | | | approved to request medical information from Kaiser. |
| but it did include a great deal of keyboarding and fine | | | | Standard did so, requesting copies of Sacks' entire |
| finger manipulation. Walking and occasional reaching | | | | medical record beginning with July 11, 2005. The |
| were a normal part of the job. | | | | medical record followed the progression of her CMT. |
| Sack's begin to experience leg pain in 2001 and began | | | | Standard's Benefits Review Board representative |
| to fall occasionally. She was diagnosed in 2003 with | | | | forwarded the entire medical record to a |
| peripheral polyneuropathy caused by | | | | board-certified neurologist. This neurologist |
| Charcot-Marie-Tooth Disease (CMT), a degenerative | | | | recommended that Sacks purchase a motorized |
| and progressive disease that causes pain and affects | | | | scooter, because he did recognize that she would |
| mobility in both legs, feet, forearms and hands. The | | | | have issues with prolonged standing, walking going up |
| disease is incurable. | | | | and down stairs, kneeling, squatting and lifting. He |
| In 2004, Sacks had to part with her three-story | | | | claimed that the low dose of Nortriptyline prescribed |
| home and move into a single level home. She fell in | | | | should not cause significant side effects that would |
| 2006 and missed a whole month of work. When she | | | | impair the ability to work. |
| returned to work she was using a walker. By 2007, | | | | The neurologist recommended that an independent |
| she had to begin taking Nortriptyline so she could | | | | medical exam (IME) be conducted to determine |
| sleep, otherwise the severe nightly leg pain | | | | whether her upper extremities were involved, |
| prevented any rest. She found the pain medication | | | | because he did not see this type of test in the |
| left her sluggish and foggy in the morning. This made | | | | record. In fact he had overlooked the EMG testing |
| it difficult to work because concentration was a | | | | that had been performed in 2006 which tested both |
| challenge. She began having to work extra long hours | | | | her legs and her arms. |
| to make up for the fact that she was inefficient in | | | | Independent Medical Exam Suggests Need for |
| the morning. This only aggravated her symptoms. | | | | Further Tests |
| Pain Becomes Unbearable. Woman Applies of | | | | Standard arranged for Sacks to undergo an IME on |
| Short-term Disability | | | | January 28, 2008. The physician Standard hired |
| On July 10, 2007, the effort to remain employed | | | | recommended that Sacks needed a repeat EMG/MC |
| became too much, and Sacks stopped working. She | | | | so that the involvement of her upper extremities |
| filed for short-term disability benefits. She explained | | | | could be studied. He told the claims representative |
| that her extreme pain and difficulty with walking | | | | that he could only determine whether or not she |
| made continuing to work impossible. On August 7, | | | | would be able to perform her job as an underwriter |
| 2007 her neurologist provided a description of her | | | | if he could draw comparisons between her previous |
| CMT diagnosis. He stated that he supported her | | | | EMG and a new one. He suspected that a disease |
| application for disability, stating that he had observed | | | | process was present and wanted to evaluate it. The |
| that her hands were becoming weaker than they had | | | | prior EMG had already shown mild bilateral carpal |
| been before and that she was dropping things. His | | | | tunnel syndrome with predominant sensory |
| notes also mentioned that she was beginning to | | | | involvement. The tested also suggested that the |
| experience difficulty with getting in and out of the | | | | right ulnar nerve was involved at the elbow. |
| car. | | | | Despite the fact that this IME suggested that Sacks' |
| Sacks sought assistance from a physical medicine and | | | | neural involvement might be significant enough to |
| rehabilitation specialist on August 13, 2007. On the | | | | support her inability to return to work, the neurologist |
| day of her visit, she was having one of her better | | | | who had performed the paper review refused to |
| days, so the doctor noted that there was no | | | | reach the same conclusion. He recommended that |
| evidence of muscular atrophy or significant weakness | | | | she should be able to perform the duties of a |
| in the peripheral regions of her limbs. He referred her | | | | sedentary job. |
| to Kaiser's orthotics department for new braces and | | | | Standard Chooses to Uphold Denial - Prefers Paper |
| recommended additional physical therapy. | | | | Review over IME Recommendations |
| Standard acknowledged that they had received | | | | Standard's March 6, 2008 denial letter was nine pages |
| Sacks claim for short-term disability benefits on | | | | long. Claiming to have evaluated her job description |
| August 24, 2007. The disability insurance company | | | | against the U.S. Department of Labor's (DOL) |
| told her that they might need additional medical, | | | | classification of an underwriter as sedentary work |
| vocational, and financial information before they could | | | | and using the DOL's definition of sedentary work, |
| make a final decision. They sent her file to a certified | | | | they listed many reasons why they were denying |
| physiatrist for a paper review. Without securing an | | | | her claim. One of the reasons included the fact that |
| accurate job description, this physician made an | | | | none of her treating physicians had seen any signs of |
| evaluation from the notes provided to Standard by | | | | disorientation during her office visits. |
| her neurologist on August 7 and her rehabilitation | | | | Sacks hires a disability attorney and takes her case |
| specialist on August 13. He determined that she was | | | | to court |
| still capable of full-time sedentary work. | | | | The first order of business for the judges reviewing |
| Standard Insurance Explains Short-term Disability | | | | this case in the U.S. District Court was to determine |
| Denial in 4-Page Letter | | | | which standard to review the court needed to use. It |
| Using this evaluation, Standard denied Sacks' claim on | | | | became immediately apparent that there was a |
| September 5, 2007. The insurance company used | | | | structural conflict of interest because Standard had |
| four pages to explain why they were denying her | | | | discretion in considering the disability claim and funded |
| benefits. The letter recognized that she was having | | | | the benefits to be dispersed under the plan. They |
| difficulty walking and standing. But the disability | | | | also made the final decision when a claimant appealed |
| insurance company did not find this compelling | | | | a denial of benefits. |
| evidence that she would be unable to perform the | | | | Her disability attorney argued that even a brief |
| material duties of her occupation. They claimed her | | | | review of the administrative record made it clear that |
| job was sedentary, and their evaluation of the | | | | Standard's claim decision had to be viewed with |
| medical evidence found her still capable of performing | | | | skepticism by the court. There was good reason to |
| the duties of a sedentary job. | | | | believe that the decision could have been influenced |
| Woman Provides Additional Information to Support | | | | by financial interests. |
| Her Disability | | | | Some of the evidence that supported this included |
| The letter told her that she could request a review | | | | the fact that despite the first denial letter being four |
| and submit additional information. She was advised to | | | | pages long, it did not provide Sacks with the |
| submit medical records dated from January 3, 2007 | | | | information she needed to support her claim. The |
| to the time of the letter. Sacks chose to appeal. On | | | | court observed that Standard used invalid |
| September 22, she provided standard with a history | | | | occupational criteria to evaluate Sacks' claim. Then |
| of the progression of her CMT. She showed how she | | | | they asked the independent medical examiner to give |
| had missed an entire month of work in 2006 because | | | | opinions based on Sacks ability to perform "any |
| of a fall. She pointed to the fact that she had only | | | | sedentary occupation" when the standard for the |
| been able to return to work using a walker. She said | | | | short-term disability application was her ability to |
| that she was wearing braces, but they no longer | | | | perform her "own occupation." |
| prevented her from falling. She also included a DVD | | | | It did not help Standard's position that they had |
| made so a prosthetic specialist could evaluate her. | | | | refused to conduct additional testing when the IME |
| She included his evaluation in her appeal. | | | | suggested it. The court found that the ignoring of |
| She noted that she was now experiencing weakness | | | | Sacks' claim that her medication impaired her ability to |
| and numbness in her hands. She claimed that she had | | | | work in the morning could not be justified. The court |
| made every effort possible to find a treatment that | | | | observed that all of her doctor's visits were in the |
| would assist her. She had tried acupuncture, physical | | | | afternoon, by which time the side effects had worn |
| therapy, prosthetics and water aerobics in addition to | | | | off. The court also found that the neurologist |
| her walker. And she reemphasized the impact her | | | | Standard hired routinely earned about $230,000 a |
| medication had upon her cognitive abilities. | | | | year providing medical consulting services to the |
| Standards response was to send her file to a nurse | | | | disability insurance provider. |
| for another paper review. This nurse commented | | | | There were other indicators that Standard had made |
| that she saw no evidence that Sacks was having a | | | | a biased decision. The insurance company had |
| problem with her medication in her medical records. | | | | determined, without any evidence to support their |
| And she did not find that the evidence Sacks | | | | conclusion, that Sacks would be able to maneuver a |
| provided supported impairment from her sedentary | | | | wheelchair with or without power. They preferred |
| occupation. When asked by the woman processing | | | | the recommendations of medical reviews that were |
| Sacks claim whether her CMT could prevent Sacks | | | | based on inadequate records-- records which were in |
| from working a sedentary job because of her inability | | | | adequate because they failed to secure the |
| to walk, the nurse attempted to contact Sacks' | | | | necessary information when they knew they needed |
| physiatrist. When she was unable to do this, she | | | | it. |
| turned to a board-certified internist. The internist | | | | |