When Symetra Life Insurance Company terminated her long term disability benefits after paying them for over three years, this school principal hired O’Ryan Law Firm to assist with her appeal for benefits. Before our client became disabled, she worked at the South Bend School Corporation as a special education teacher for 11 years, then as a Principal. The South Bend Community School Corporation (“SBCSC”) operates the public schools in South Bend, Indiana, and is one of the largest school corporations in Indiana, with a total of 34 schools. It serves most of South Bend, Indian Village, Notre Dame, and Roseland, as well as portions of Granger and Mishawaka.
Symetra Life Insurance Company (”Symetra”) is an Iowa corporation doing business in Indiana. Symetra’s principal place of business is in Seattle, Washington. Pursuant to the disability policy, Symetra promises to pay monthly disability benefit payments in the event our client was unable to work due to injury or sickness.
Our client worked for South Bend School Corporation until May 2014, when she was forced to stop working after she was diagnosed with hemiplegic migraines and trigeminal neuralgia. Hemiplegic migraines or Hemiplegic migraine headache is a rare and serious subtype of classical migraine that typically includes weakness of half the body which can last for hours, days or weeks. It can be accompanied by other symptoms, such as ataxia, coma and paralysis. Trigeminal neuralgia is a chronic pain condition that affects the trigeminal nerve, which carries sensation from your face to your brain. If you have trigeminal neuralgia, even mild stimulation of your face — such as from brushing your teeth or putting on makeup — may trigger a jolt of excruciating facial pain. Our client also suffers from Sarcoidosis, an inflammatory disease characterized by the formation of granulomas—tiny clumps of inflammatory cells—in one or more organs of the body. When the immune system goes into overdrive and too many of these clumps form, they can interfere with an organ’s structure and function. When left unchecked, chronic inflammation can lead to fibrosis, which is the permanent scarring of organ tissue. This disorder affects the lungs in approximately 90% of cases, but it can affect almost any organ in the body. Despite increasing advances in research, sarcoidosis remains difficult to treat.
The lawsuit against Symetra Life Insurance Company includes the following allegations:
On December 9, 2014, Symetra determined that Ms. Carlson was disabled under the terms of the policy and paid Ms. Carlson disability benefits until March 5, 2019. Accordingly, Symetra paid disability benefits to Ms. Carlson for a total of 52 months, 36 months under the “own occupation” time period and 16 months under the “any occupation” time period.
On March 5, 2019, Symetra wrongfully terminated Ms. Carlson’s without medical evidence showing improvement in her medical conditions. To the contrary, the medical evidence and reports from the treating physicians establish that Ms. Carlson continues to be unable to return to work.
Ms. Carlson is disabled, meets the policy definition of disabled and has provided Symetra with substantial medical records and physician reports that establish that she continues to meet the requirements of the disability policy. Ms. Carlson’s physicians advised Symetra that Ms. Carlson is unable to work due to her serious medical conditions. For instance, Dr. Yount, from Northcentral Neurosurgery, reported to Symetra:
Ms. Carlson continues to suffer from disabling recurrent trigeminal neuralgia in addition to cluster headaches. Managing this pain requires her to take high doses of medication that affect her ability to concentrate and perform her job efficiently. Her pain is significantly worsened by stress and when she gets worse, she requires higher doses of medication which make it even harder for her to function. I recommend that she consider permanent disability.
Dr. Kevin Kristl reported to Symetra a few months before their termination of benefits:
Patient can no longer work and should be considered permanently disabled.
In further support of Ms. Carlson’s claim, the Social Security Administration approved Ms. Carlson for Social Security Disability Income benefits. The Social Security Administration found that Ms. Carlson is unable to engage in any substantial gainful activity.
In fact, Symetra hired the law firm of Doherty Cella Keane to represent Ms. Carlson in her Social Security disability claim with the federal government. Symetra knowingly hired counsel for Ms. Carlson whom then represented to the federal government that she was totally disabled so that Symetra could gain the financial benefit of an SSDI offset. Subsequently, Symetra terminated her disability benefits, under the same or similar standard, arguing that she was no longer disabled. Symetra consciously disregarded the findings of the Social Security Administration, despite their role in advocating for Ms. Carlson’s SSDI award, to reach their faulty conclusion that Ms. Carlson was no longer disabled.
Symetra terminated this complex medical claim based upon the opinion of a single record reviewer. The record reviewer does not have the appropriate qualifications to render opinions on the diagnoses given Ms. Carlson by her multiple physicians and specialists.
Symetra found the record reviewer through “PDA”, a company who supplies record reviewers to disability insurance companies for reviewing medical records and generating reports. PDA does not provide this service to claimants. PDA receives a tremendous amount of money from the disability insurance industry, including Symetra, for record reviews thus creating a significant financial conflict of interest leading to biased outcomes in the disability claims handled by PDA. PDA does not provide fair and objective record reviews and did not provide a reasonable and objective record review in this case. Symetra chose PDA to perform the record review in this case knowing that there was a high probability that Symetra would receive a record review favoring termination of the claim.
The record reviewer’s opinion was contrary to the medical evidence and the reports of the treating physicians. For instance, the record reviewer opined, despite the fact that Symetra had paid Ms. Carlson benefits until March 5, 2019, that Ms. Carlson has not been disabled since 2014.
Before the record reviewer concluded that Ms. Carlson was not disabled, Ms. Carlson’s physician, Dr. Bryon Thomas, reported to the record reviewer:
You report that your patient never has a “normal” exam: you described right facial droop, minimally slurred speech, intermittent left-sided body weakness, altered gait that requires use of a cane because her left side “gives out.” You thought that her knee injury might have been related to a fall caused by the giving out of the left side. You reported that her hemiplegic migraines have decreased with starting the new medication, Aimovig. However, her trigeminal neuralgia is still a problem, causing her severe intermittent pain. You report that she usually follows with you when she is doing better; that when she has flare ups, she goes to the ER. Reported that her hospital admission notes may provide more detailed exam findings for the times when her symptoms and physical exam are worse. You report she is not driving. You report her hemiplegic migraines as occurring once every few months, though she has headaches on a much more regular basis. She deals with the trigeminal neuralgia flares more often than the hemiplegic migraines. You do not feel she can work on account of her trigeminal neuralgia and hemiplegic migraines.
Before the record reviewer concluded that Ms. Carlson was not disabled, Ms. Carlson’s physician, Dr. Kevin Kristl, reported to the record reviewer:
You feel that she is drastically limited in her functional status based upon her hemiplegic migraines and trigeminal neuralgia. Related to these conditions, the claimant has episodes of vision loss and needs to use a cane and/or walker to ambulate. You stated the claimant has extreme pain…[S]he is having more trouble with sharp pains around her eyes…She has been hospitalized multiple times in the past…
Ms. Carlson’s physical therapist, reported to the record reviewer, in her own words:
During the phone conversation I did not agree with you that Ms. Carlson is able to return to work. She has been off work on disability as determined per her physicians prior to her coming into our clinic for treatment after she was diagnosed with trigeminal neuralgia. I did refer you back to the notes and confirmed she has issues with balance and lower extremity strength. I also stated she has good attendance with her appointments and as necessary rescheduled any within the same week.
The record reviewer utilized by Symetra acknowledged that she was not able to evaluate the severity of Ms. Carlson’s diagnosis of Internuclear Opthalmoplegia, a serious eye condition. Despite this admission, Symetra did not hire a specialist to review the medical records specifically for this condition. Symetra knowingly failed to hire the requisite eye specialist to review the medical records regarding this condition.
Moreover, the record reviewer reported “[i]t appears the claimant has had multiple ER visits and hospital stays, though few are fully documented in the available record.” Despite the record reviewer’s acknowledgement that she was lacking critical medical records, Symetra made no attempt to obtain the hospitalization records from Ms. Carlson’s multiple hospitalizations.
Although the policy authorizes Symetra to request an Independent Medical Exam, Symetra did not request that Ms. Carlson submit to an Independent Medical Exam despite her chronic, multiple, severe medical conditions. Rather, Symetra relied upon a single record review generated by a physician who is not board certified in any of the appropriate specialties.
Lastly, in its April 4, 2019, termination letter, Symetra argued that Ms. Carlson could perform the jobs of Special Education Administrator, Director Special Education, Certification & Selection Specialist, to justify their termination of the disability benefits. These are very advanced positions in the education field. Ms. Carlson does not have the requisite advanced education, and as a consequence the mandatory certification, for these advanced positions nor the training or experience for these positions. Symetra has been fully informed of Ms. Carlson’s education, training and experience. Ms. Carlson’s past training, education and experience would clearly not be sufficient for the jobs proposed by Symetra. Accordingly, Symetra knowingly utilized false information to support their termination of the disability payments.
If you have had a disability claim denied by Symetra Life Insurance Company, please contact the O’Ryan Law Firm as soon as possible.