Most ERISA plans contain provisions limiting benefits for disabilities “which are primarily based on self-reported symptoms” or “mental illness.” (Emphasis added).

So, what does “primarily” mean? And what evidence in the medical records justifies the conclusion that the diagnosis is primarily based on self-reported symptoms?

Here’s a new case that highlights that the limitation still applies even when there might be some weak evidence in the medical records verifying the diagnosis. That’s because the diagnosis rested “primarily” on self-reported symptoms. Floerke v. SSM Health Care Plan and Unum Life Ins. Co., 2018 WL 5045770 (W.D. Wisc. October 17, 2018)(Relying on nurse reviews, Unum properly discontinued benefits after concluding the diagnosis of headaches was primarily based on self-reported symptoms and discontinued benefits).

FACTS: Floerke sought ERISA-governed disability benefits as a result of “chronic daily persistent headaches” and anxiety. UNUM, vested with discretion in making the claim determination, discontinued benefits after 12 months under the “self-reported symptoms” limitation, which applies to disabilities “which are primarily based on self-reported symptoms” or “mental illness.” (Italics added). Floerke sued alleging wrongful denial of benefits.

ISSUES: Whether Plaintiff’s chronic migraine diagnosis was primarily based on medical records, tests and physical exams which sufficiently verified her condition?

DISTRICT COURT HELD: NO. Unum did not abuse its discretion in discontinuing benefits.

  1. Plaintiff argued the self-reported symptoms limitation should not apply because the diagnosis was primarily based on her medical history, physical exam, and “a process of exclusion diagnosed through standard clinical practice.” This medical information included “evidence of increased spinal pressure,” and muscle tenderness and range of motion limitations. Op. at 17.
  2. “[T]he self-reported limitation applies only to the method used to diagnose the sickness or injury that [led] to the disability, and not the symptoms of the claimed disability itself.” Op. at 17.
  3. Floerke’s clinical migraine diagnosis was based primarily on self-reported symptoms. Op. at 18.
  4. Evidence of “increased spinal fluid pressure” was not verifiable evidence confirming the headaches because the medical records did not consistently establish she had increased spinal fluid pressure, or that it was the cause of the headaches. Op. at 19.
  5. Unum properly relied on nurses’ analyses concluding that the medical records failed to verify Floerke’s headaches. Op. at 23.