More and more frequently, employees in Chicago on long term disability through an employer-sponsored disability plan are facing benefit terminations for conditions such as Fibromyalgia and Chronic Fatigue Syndrome because of a so called “self reported symptoms” limitation in the long term disability policy. Insurers more frequently place these limiting clauses in disability policies, assuming they would dispose of all the Fibromyalgia and Chronic Fatigue Syndrome cases within 24 months. But not so fast. After withdrawing its opinion in Weitzenkamp v. Unum Life Insurance Co. of America, the Seventh Circuit Court of Appeals reissued an opinion, again ruling in favor of the claimant, but on different grounds. 2011 U.S. App. LEXIS 19283, 2011 WL 4375637 (7th Cir. Sept. 20, 2011).
I previously covered this opinion, and he suspicion for why the court may have withdrawn its opinion. This time, the Seventh Circuit held that although the limitation on self reported symptoms was a part of the plan, it did not apply in Weitzenkamp’s case. The limitation in this policy could be construed one of two ways. Either a limitation that limit applicable to all disabilities where the disabling conditions are self-reported symptoms, as UNUM proposed, or as a limit on disabilities where the diagnosis of the condition is based primarily on self reporting of symptoms. The Seventh Circuit held that the latter construction was more reasonable. With every condition, it is not the condition itself that disables the person, but the pain, weakness, etc. associated therewith that renders the person disabled. To construe the limitation as UNUM suggested would literally cause every disabled person to have his or her benefits limited to 24 months pursuant to one of these clauses. Because in Weitzenkamp’s case, the physicians had considered plenty of other data along with the self reported symptoms, the court held the limitation did not apply.
The lesson to be learned from Weitzenkamp is to make sure a doctor treating you for Fibromyalgia or Chronic Fatigue Syndrome runs appropriate tests to rule out other possibilities before diagnosing your condition. If the doctor does so, and your plan has a clause like the one in Weitzenkamp, you may be able to avoid application of such a limitation. If you have questions about a self-reported symptoms limitation, speak with a knowledgeable ERISA attorney.