Short-Term Disability Claim Denial Based on Back Pain Claim Upheld – Medical Diagnosis Alone Insufficient to Support Claim

Short-Term Disability Claim Denial Based on Back Pain Claim Upheld – Medical Diagnosis Alone Insufficient to Support Claim

The District Court of Minnesota, in Braden v. ATT Umbrella Benefit Plan No. 3, 2017 WL 1047257 (D. Minn. Mar. 17, 2017), granted summary judgment under ERISA in favor of the plan in spite of medical evidence that the claimant could not work based on lumbar pain and degenerative disc disease. The decision is worth reading because of the court’s thoughtful assessment of the evidence and rejection of the notion that a person with a documented history of back surgery, reports of inability to sit at work and a supporting physician’s opinion is entitled to short-term disability benefits.

At first blush, Mr. Braden’s claim appeared to be payable. He had a sedentary job as Customer Service Specialist which involved a significant amount of sitting and he presented as “objective medical information” (the Plan’s requirement): two lumbar surgeries within 18 months; an MRI showing bulging discs; treating physician records and statements; and pain complaints. Indeed, the claims administrator (Sedgwick) initially approved the claim for a three-week period, relying upon a physician file review.

Upon further review, however, Sedgwick denied Braden’s request for additional benefits, in part because his claim was based on self-reported symptoms which the plan expressly stated was insufficient — “standing alone” — to support disability. Five weeks after his benefits ended, Braden returned to work on part-time basis for 20 hours a week and submitted another statement from his treating physician that he could not sit for more than 30 minutes without standing or walking. He also submitted notes from a specialist physician and a spinal specialist. In response to Mr. Braden’s submissions (supporting his renewed claim, and on appeal), Sedgwick obtained three additional physician reviews (specialists in occupational medicine, neurosurgery, and physical medicine/rehabilitation). Those reviewers each opined that Braden’s MRI did not demonstrate any objective impairment – and, presumably, relying upon Braden’s treating physician’s statement that his symptoms were not supported by objective findings, concluded that that his condition did not render him unable to work in his own occupation.

Judge David Doty’s opinion addressed each of Braden’s arguments in the administrative record and found that Sedgwick’s decision was supported by substantial evidence, McGee v. Reliance Standard Life Ins. Co., 360 F.3d 921 (8th Cir. 2004). Given the frequency in which these arguments are presented to courts in disability claims, two aspects of the decision merit special attention:

  • First, the judge concluded that Braden’s two prior surgeries and limited range of motion were insufficient to prove disability, acknowledging the reviewing physicians’ consensus that his claim was mostly based on self-reported symptoms. Though not expressly noted, the opinion suggests that Braden’s claim was weakened by the absence of any precipitating event or objective medical test occurring at the time he stopped working.
  • Second, Sedgwick was not bound to continue approving benefits based on the evidence supporting its initial approval given that it obtained additional specialized physician reviews and reviewed all of the records and MRI reports Braden submitted during the claims review process. Sedgwick paid the claim when it was supported under the plan terms and ceased paying the claim when additional evidence confirmed that Mr. Braden was no longer entitled to benefits.

Originally published on DRI‘s members-only site.