Court: U.S. District Court for the Northern District of California
Insurance Carrier: Sun Life and Health Insurance Company, Inc.
Claimant’s Employer: Physiatry Medical Group, Inc.
Claimant’s Occupation: Physician
Background: A Physician’s Battle with Chronic Fatigue Syndrome
Dr. Jerry Sobel, a physician employed by Physiatry Medical Group, Inc., began experiencing severe symptoms in September 2006, including extreme fatigue, a racing heart, severe cough, and other debilitating problems. He was diagnosed with whooping cough, Epstein-Barr virus, and chronic fatigue syndrome by several medical professionals and stopped working in December 2006. Despite his condition, Dr. Sobel’s initial claim for long-term disability benefits, filed in February 2007, was denied by Sun Life, the disability plan’s insurer.
Denial of Benefits: Questionable Psychiatric Connections
Sun Life denied Dr. Sobel’s claim based on evaluations by its consultants, who concluded that his symptoms were not consistent with chronic fatigue syndrome and were possibly psychiatric in origin. The denial relied heavily on the lack of clear diagnostic criteria supporting the condition and the discovery of prior psychiatric treatment, specifically a prior diagnosis of major depressive disorder. Sun Life also conducted a productivity analysis suggesting that Dr. Sobel’s billing activity before he stopped working indicated full-time performance. In addition, Sun Life insisted on an independent neuropsychiatric evaluation, which Dr. Sobel refused, citing inappropriate timing after the initial denial.
Litigation: Plaintiff Challenges Insurer’s Conclusions
Dr. Sobel filed suit under ERISA to recover the denied benefits. He argued that Sun Life’s reliance on psychiatric history and selective application of diagnostic criteria was unreasonable. He also claimed that the insurer’s request for an independent examination was unreasonable because it was not made during the initial claim review process.
The court found that key factual findings were missing, particularly with respect to whether Dr. Sobel’s chronic fatigue was caused by psychiatric conditions. It noted that Sun Life selectively cited guidelines to deny the claim, and raised concerns about its inconsistent use of diagnostic criteria.
Court’s Decision: Remand for Further Review
The court stayed Sun Life’s motion for summary judgment and remanded the case for further consideration. It ordered the plan administrator to:
- Conduct an independent neuropsychiatric evaluation to rule out psychiatric causes of Dr. Sobel’s fatigue.
- Review all relevant medical records, including psychiatric records previously omitted from the administrative record.
- Resolve ambiguities in favor of the claimant, particularly in applying the diagnostic criteria for chronic fatigue syndrome.
The court emphasized the need for Sun Life to conduct a fair and impartial reevaluation, ensuring that all evidence is thoroughly and properly considered.
Get Help with Your Long-Term Disability Claim Denial
Dr. Sobel’s case highlights the challenges many professionals face when navigating complex disability claims. If you are a medical professional struggling with a denied long-term disability claim, contact the Ortiz Law Firm for guidance and advocacy tailored to your situation. We specialize in helping clients like you secure the benefits they deserve. Call (888) 321-8131 to schedule a free case evaluation today.
Disclaimer: This case was not handled by disability attorney Nick A. Ortiz. The court case is summarized here to give readers a better understanding of how Federal Courts decide long-term disability ERISA claims.
Here is a PDF copy of the decision: Sobel v. Sun Life
