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United Regional Healthcare Coordinator with Arthritis Wins Lincoln Financial Appeal
The case involves a patient care coordinator who developed multiple physical and mental health conditions that eventually prevented her from continuing to work. She suffered from severe osteoarthritis in both knees that required bilateral knee replacements, severe shoulder osteoarthritis requiring surgery, and degenerative disc disease. These conditions caused significant pain and made prolonged sitting and standing difficult. Her pain also interfered with her ability to focus and concentrate, and she experienced depression and anxiety related to her ongoing physical symptoms.
Lincoln Financial initially approved the client’s long-term disability claim and paid benefits for 24 months, agreeing that she could no longer perform her occupation. At the 24-month mark, however, the policy’s definition of disability changed from an own-occupation standard to an any-gainful-occupation standard. Lincoln identified several alternative occupations that it believed the client could perform, primarily sedentary positions involving activities such as reviewing records or performing managerial work.
The problem with Lincoln’s reasoning was that the client’s previous occupation as a patient care coordinator was itself largely sedentary. Lincoln had already determined that her physical and cognitive limitations prevented her from performing that job, yet at the definition change it concluded that she could perform other sedentary occupations for 40 hours per week. Lincoln relied on physicians who performed paper reviews of the medical records and never personally examined the client. Her own treating physicians continued to support her inability to work, and she had also been approved for Social Security disability benefits.
Attorney Rachel Alters developed an appeal focused on demonstrating why the client could not reliably sustain full-time sedentary employment. Key components included:
- Arranging a Functional Capacity Evaluation (FCE), which concluded that the client could not perform sedentary work.
- Hiring a vocational expert to evaluate the occupations identified by Lincoln in light of the client’s medical conditions, education, experience, restrictions, and limitations.
- Working closely with the client’s treating physicians to respond to the conclusions reached by Lincoln’s reviewing doctors.
- Providing the treating physicians with the FCE and vocational report so they could evaluate whether the findings were consistent with their own treatment and examinations.
- Preparing customized Attending Physician Statements asking the doctors to specifically address whether the client could sustain full-time sedentary employment.
- Documenting the objective medical testing and clinical findings supporting the physicians’ opinions regarding her restrictions and limitations.
The FCE provided particularly important evidence because it directly evaluated the physical capabilities at issue in Lincoln’s denial and definitively supported that she could not sustain sedentary work. The vocational evaluation separately challenged Lincoln’s conclusion that other occupations were realistically available given her functional limitations. Together, these reports provided the client’s treating physicians with additional evidence they could review and incorporate into their own opinions.
The treating physicians strongly supported the appeal. After reviewing the functional and vocational evidence, they explained why the client’s medical conditions, chronic pain, limitations with sitting and standing, medication side effects, and difficulties with focus and concentration prevented her from reliably performing a full-time sedentary occupation. Their opinions were incorporated into customized physician statements and