“Limited Disability Benefits” Clauses in Chronic Fatigue Syndrome Disability Insurance Claims

Many disability policies or plans have subjective medical condition or limited disability benefit clauses that will limit the payment of disability benefits to just 24 months. There is often a fight about the terms of these limited disability clauses and whether a particular medical condition falls within the limited disability benefits clause.

That is exactly what happened in the case of Tucker v. Express Scripts Health & Welfare Benefits Plan, 2022 WL 88143 (E.D. Mo. Mar. 25, 2022). Mr. Tucker was covered under a disability plan that had a “Limited Disability Benefits” clause that limited the payment of disability benefits after 24 months for certain conditions, including chronic fatigue syndrome.

When faced with such a policy limitation there are typically two arguments a claimant can make:

1. that the policy limitation is poorly written, and/or

2. that the disabling condition is not one of the limited benefit

In Tucker’s case, benefits for chronic fatigue syndrome was limited to just 24 months. The disability plan found Tucker was disabled by chronic fatigue syndrome and denied his claim for benefits more than 24 months. His case ended up in federal court.

Tucker’s Response to Express Scripts Health and Welfare CFS Claims

One approach to counter the limited disability clause is to argue that you are disabled because of medical conditions not listed in the limited disability benefit clause.

Tucker’s argument was that he was “not disabled by Chronic Fatigue [but] by post-viral chronic fatigue syndrome, fibromyalgia, and chronic Epstein-Barr infection!”

This approach can be tricky for several reasons. First, many disability policies or plans have a discretionary clause which is like a get out of jail free card for the disability carrier or plan. The reason is that a judge must defer to the carrier or plan’s interpretation of the terms set forth in the “limited disability benefits” clause, unless that interpretation is unreasonable.

Second, the judge will review the carrier’s medical analysis and conclusions about what medical condition(s) are the cause of the disability and whether those medical conditions are excluded by the limited disability benefit clause.

Tucker argued that his disabling diseases were post-viral chronic fatigue syndrome (CFS), fibromyalgia, and a chronic Epstein-Barr virus (EBV) infection. He argued that Epstein-Barr is not one of the limited benefits conditions.

However, the plan had determined that he was disabled because of chronic fatigue and not the chronic EBV infection. Tucker’s physician and the plan’s physicians relied on the same medical article about the relationship between CFS and Epstein-Barr but reached opposite conclusions.

Under ERISA case law, a disability insurance carrier or plan does not have to accept the opinion of the treating doctor over that of its own doctors. The court found that it was not an abuse of discretion for the carrier to accept the opinions of its physicians and their interpretations of medical literature over that of Tucker’s physicians.

As a result, the denial was upheld.

Suffer From Chronic Fatigue Syndrome? Don’t Give Up

Regardless of the approach, the disability policy holder or plan beneficiary has the burden of proving entitlement to their disability benefits.

While disability carriers are in the business of denying disability insurance claims you shouldn’t give up! If you have been denied a claim, contact our Anthem disability claim attorney today.

Why Cavey Law Is The Right Attorney To Fight For Your CFS Disability Claim

Nancy Cavey, whose father became disabled when she was a teenager, knows first hand how difficult it is to make the decision to stop work and apply for the disability benefits you have been paying for! Her father struggled for years before making that decision.

Nancy Cavey can

– review your disability insurance policy or plan and explain what you must do to get both your short and long disability benefits for CFS or Epstein-Barr,

– guide you through the decision to stop work and help you file your claim for short- and long-term disability benefits,

– explain any subjective medical condition or limited benefit clauses in your policy or plan and discuss a strategy for addressing these limitations,

– submit your disability insurance application, appeal a wrongful denial or termination, file a lawsuit in federal court, and negotiate a lump sum.

 

Call today at 727-894-3188 for a free consultation and learn more about your rights to your disability insurance benefits regardless of where you live in the U.S.