Conti v. Lincoln National Life Insurance Company, The

Background

Christina Conti sued The Lincoln National Life Insurance Company under the Employee Retirement Income Security Act of 1974 (ERISA), seeking long-term disability benefits under a plan purchased for Veolia North America. Conti stopped working in March 2019 because of widespread pain, weakness, numbness, and related symptoms. Her diagnosed conditions included fibromyalgia, arthralgia at multiple sites, and small fiber neuropathy.

The plan defined disability during the first 24 months as an injury or sickness preventing performance of the material and substantial duties of the claimant’s occupation. After 24 months, the claimant had to show an inability to perform any occupation for which the claimant was reasonably fitted by training, education, experience, age, and physical and mental capacity. Lincoln classified Conti’s job as a light-duty radiation-monitor position involving lifting up to 20 pounds, frequent walking or standing, and pushing or pulling controls.

Lincoln initially approved short-term disability benefits and later approved long-term disability benefits effective September 11, 2019. Lincoln suspended Conti’s benefits effective July 21, 2021, citing missing updated records from several providers. After a file review by Dr. Stephen Broomes, Lincoln determined that the objective clinical findings did not support continuing work restrictions. Following Conti’s appeal and another review by Dr. Karen Oldham, Lincoln denied the appeal on January 31, 2022.

The parties’ motions and standard of review

Conti and Lincoln each moved for judgment on the administrative record under Federal Rule of Civil Procedure 52. The parties agreed that the court should review the benefits decision de novo, meaning the court would decide the facts, weigh the evidence, and apply the plan’s terms without deferring to Lincoln’s decision. Conti had the burden to prove by a preponderance of the evidence that she was entitled to benefits.

Merits analysis

The court held that the plan did not require Conti to provide proof of disability continuously. Instead, the plan required proof of continued disability after Lincoln requested it, and benefits were payable for the period supported by that proof. The court found that Lincoln had not clearly told Conti what evidence of her physical limitations it wanted. Lincoln also could have required a functional-capacity examination but did not do so. The court concluded that Lincoln’s vague requests, followed by reliance on the absence of functional-capacity evidence, weighed against the denial.

The court gave significant weight to the evidence concerning fibromyalgia. Conti had been diagnosed with severe fibromyalgia after showing tenderness at all 18 diagnostic trigger points. The court explained that normal physical examinations and unremarkable test results did not disprove fibromyalgia or show that Conti was exaggerating her symptoms. The court also considered evidence of small fiber neuropathy and arthralgia, Conti’s consistent reports of pain and fatigue, and the effect of those symptoms on activities such as standing, walking, sitting, shopping, caring for herself, and caring for her family.

The court found Dr. Robert Palguta, Conti’s treating physician, credible. Apart from a May 2021 form that indicated light-duty work was possible, which Dr. Palguta later said did not authorize Conti to work, he consistently concluded that Conti could not work. The court viewed the May 2021 notation as an error that Dr. Palguta later corrected.

The court found weaknesses in the reviews by Dr. Broomes and Dr. Oldham because neither addressed fibromyalgia, which was Conti’s primary diagnosis. Their reliance on normal examinations and a lack of objective capacity testing did not sufficiently explain why Conti’s reported limitations and Dr. Palguta’s opinions should be rejected. The court also considered Conti’s Social Security disability award, while noting that the award was not binding, and Lincoln’s prior payments of disability benefits. The court found that Conti’s fibromyalgia-related evidence and reported limitations had not significantly changed before July 21, 2021.

Benefits after July 21, 2021

The court found that Conti remained disabled throughout the plan’s “own occupation” period. Because the plan changed to the “any occupation” standard on September 11, 2021, the court concluded that the record did not contain enough evidence to decide Conti’s eligibility under that later standard. The court remanded that question to Lincoln for an actual determination based on Conti’s physical capacity or her failure to comply with a specific request for evidence needed to make the determination.

The court ordered ongoing benefits until Lincoln determines that Conti is not disabled under the “any occupation” standard or the plan otherwise permits termination. The court stated that Lincoln may resume its eligibility review immediately, but must continue paying benefits until it makes that determination or takes another proper action under the plan.

Order

The court denied Lincoln’s motion for judgment under Rule 52 and granted Conti’s motion for judgment under Rule 52. It ordered Lincoln to pay Conti all unpaid long-term disability benefits from July 21, 2021, to the present, with the amount to be determined. The court ordered the parties to meet and confer about the benefits owed, attorney’s fees, costs, and prejudgment interest. It did not determine those amounts in the order; instead, it set procedures for submitting an agreed judgment or additional filings if the parties disagreed.