Our client Gloria Archuleta worked as a customer service representative, a job that require sitting for hours at a time. Ms. Archuleta began to experience severe pain and sudden attacks on her right side, making sitting impossible for more than brief periods. Although Ms. Archuleta underwent surgery, her pain remained. She was subsequently prescribed strong pain medication, which left her feeling “sleepy” and “fuzzy-headed,” and further interfered with her ability to perform her job functions. Nevertheless, her ERISA insurance carrier Reliance Standard Life Insurance Company terminated her benefits.
The trial court held, in a published opinion, that Reliance Standard acted in an arbitrary and capricious manner when it ignored Ms. Archuleta’s reports of pain and failed to investigate or consider the side effects of her pain medication. Archuleta v. Reliance Standard Life Ins. Co., 504 F.Supp2d 876 (C.D. Cal. 2007).
“A claims decision that does not consider the effects of narcotic medication on the ability of one to perform an occupation has been held to be arbitrary and capricious under the strict deferential review standard,” wrote the court.
The Archuleta court relied on case law to reach its decision. In Gaither v. Aetna Life Insurance Company, 394 F.3d 792 (10th Cir. 2004), the 10th Circuit found that a fiduciary cannot shut its eyes to readily available information that suggests evidence will support the claim. In that case, Aetna should have investigated the effects of the claimant’s narcotic medication.
In addition, the court cited Adams v. Prudential Insurance Company of America, 280 F. Supp.2d 731 (N.D. Ohio 2003), which found the insurer’s failure to consider the side effects of Oxycontin was arbitrary and capricious.
While courts have become friendlier to arguments proving the disabling side effects of medications, not everyone is comfortable with the fact that medicine which makes you feel better can also keep you from being normally productive. As a result, patients and doctors are not documenting the effects of medications as fully as necessary for insurance purposes. We’ve noticed a few reasons why.
First, when patients finally get pain relief, or know that medicine is keeping them alive, they may not want to appear ungrateful by complaining about feeling dizzy or nauseous. They may determine they have to live with the side-effects, even when the side-effects begin to seriously affect work performance or quality of life, such as being unable to drive a car.
Second, some doctors don’t want to acknowledge that the treatment or cure is worse than the disease, or may trade one set of problems for another. They are in the business of healing, and as long as the medication is performing its major function of alleviating pain or suppressing other symptoms, they tend not to probe too deeply.
Third, pharmaceutical companies – even though they publish long lists of potential side effects as legal disclaimers – stand behind the abilities of their drugs once they reach FDA approval. To focus too heavily on side effects could undermine consumer confidence in their products.
Nonetheless, it is critical that people suffering from disabling side-effects of medications fully report and document their symptoms, particularly when the effects are so severe that working or even functioning normally becomes impossible. Medical doctors should include these complaints in their office notes and in their communications to insurance companies explaining their diagnoses and recommendations, particularly if the patient has tried every other treatment but can only find relief with the medication that produces serious side-effects.