Ruling on Need for Objective Evidence to Prove LTD Claim
Mitchell v. Eastman Kodak decision
The following summary of an appellate court decision should be helpful for any person with an illness such as CFIDS for which there is no known objective test to prove the cause or severity of the disability.
The full text of this decision Mitchell v. Eastman Kodak, docket # 96-7034 (May 8) is available on the Internet at: http://www.ljextra.com/courthouse/feddec.html- Go to decisions filed on May 8, 1997.
Filed May 8, 1997 UNITED STATES COURT OF APPEALS FOR THE THIRD CIRCUIT NO. 96-7034 GEORGE W. MITCHELL v. EASTMAN KODAK COMPANY Appellant According to the record before us, the Administrator denied Mitchell's claim for LTD benefits because Mitchell had failed to tender "objective medical evidence" that he was unable to engage in any substantial gainful work as of June 26, 1989. We hold that, in this context, it was arbitrary and capricious for the Administrator to deny Mitchell LTD benefits for this reason.
I. See Letter of Jan. 17, 1992, App. at 24 ("The file indicates that you are suffering from fatigue, but does not contain objective medical evidence that your condition made you totally and continuously unable to engage in any substantial gainful work for which you were qualified as of June 26, 1989.") (emphasis in original); Letter of Apr. 12, 1995, App. at 193 (informing Mitchell's attorney that denial of benefits was affirmed because "you and your client have failed to provide any objective medical evidence that his condition made him totally and continuously unable to engage in any substantial gainful activity for which he was qualified as of June 26, 1989.") (emphasis in original).
The Administrator's denial letters are terse, and we are not altogether certain of their meaning. However, we find the denial arbitrary and capricious under either of the possible meanings we can divine. The Administrator may have meant that Mitchell had tendered insufficient evidence to persuade the Administrator that Mitchell experienced chronic and unpredictable fatigue and loss of concentration or that he experienced those symptoms to a sufficient extent to foreclose his holding down paid employment. If that was the Administrator's meaning, his denial of benefits on that ground was arbitrary and capricious because the undisputed facts of record are to the contrary. As we have already described, the undisputed evidence from Mitchell's physicians indicates that Mitchell has suffered severe CFS symptoms that have precluded him from engaging in any substantial gainful work since January 1989. Kodak has identified no more "objective" evidence that Mitchell could have submitted, in addition to his doctors' observations, to support his claim that his fatigue and loss of concentration were sufficiently severe to prevent him from engaging in ainful work.
Because the Administrator cited a lack of "objective medical evidence," as opposed to merely "objective evidence," we think it more likely that the Administrator meant that Mitchell had failed to submit clinical evidence establishing the etiology of the chronic and unpredictable fatigue and loss of concentration that disabled him from working. Although in some contexts it may not be arbitrary and capricious to require clinical evidence of the etiology of allegedly disabling symptoms in order to verify that there is no malingering, we conclude that it was arbitrary and capricious to require such evidence in the context of this Plan and CFS.
The Plan requires that a claimant for LTD benefits "[m]eet the definition of Disability," i.e. be "totally and continuously unable to engage in any substantial Gainful Work for which he is, or becomes, reasonably qualified" for at least 26 weeks. See Plan §§ 2.06, 4.01. Nowhere does the Plan state that a claimant must provide clinical evidence of the etiology of the "condition" that renders him disabled. Cf. Dewitt v. Penn-Del Directory Corp., 106 F.3d 514, 520 (3d Cir. 1997) (administrator's discretionary interpretation of plan "may not controvert the plain language of the [plan] document") (citing Gaines v. Amalgamated Ins. Fund, 753 .2d 288, 289 (3d Cir. 1985)). All that the Plan required was that Mitchell show that he was in fact "disabled" as of June 26, 1989, and this he did. See supra Part II-B-2.
Moreover, it was impermissible for the Administrator to imply an additional "clinical evidence of etiology" requirement not specified in the Plan document in the context of CFS. It is now widely-recognized in the medical and legal communities that "there is no `dipstick' laboratory test for chronic fatigue syndrome." Sisco v. United States Dep't of Health & Human Services, 10 F.3d 739, 744 (10th Cir. 1993). Because the disease, although universally- recognized as a severe disability, has no known etiology, see, e.g., Rose v. Shalala, 34 F.3d 13, 16-17 (1st Cir. 1994), it would defeat the legitimate expectations of participants in the Kodak Plan to require those with CFS to make a showing of clinical evidence of such etiology as a condition of eligibility for LTD benefits. Thus, it was arbitrary and capricious for the Administrator to deny Mitchell benefits because of a lack of such clinical evidence of the etiology of his CFS
III. Conclusion In accordance with the foregoing, we hold that the Kodak Plan Administrator's decision to deny Mitchell's claim for LTD benefits was "arbitrary and capricious." We will affirm the district court's grant of summary judgment for Mitchell.
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Clerk of the United States Court of Appeals for the Third Circuit