United States District Court, District of Columbia
N. MCFADDEN UNITED STATES DISTRICT JUDGE.
case involves the fraught question of insurance coverage for
individuals with symptoms associated with Lyme disease.
Wesley Loucka brought this action under the Employee
Retirement Income Security Act of 1974, see 29
U.S.C. § 1132, claiming that Lincoln National Life
Insurance Company improperly denied him disability benefits.
Mr. Loucka says that Lincoln unreasonably concluded that he
suffers from Chronic Fatigue Syndrome (“CFS”), a
condition that the relevant policy limits to 24 months of
long-term disability benefits. He asserts the he has Lyme
disease, which is not subject to the policy's 24-month
benefits limitation. Lincoln, however, maintains that the
medical evidence shows that Mr. Loucka does not have Lyme
disease and his symptoms suggest CFS. The parties have filed
cross motions for summary judgment. Mr. Loucka has also moved
to strike exhibits from Lincoln's summary judgment
papers. For the reasons explained below, Mr. Loucka's
Motion to Strike will be denied, his Motion for Summary
Judgment will be denied, and Lincoln's Cross Motion for
Summary Judgment will be granted.
Loucka worked as a Systems Administrator at NOVA Corporation,
which offered its employees long-term disability coverage
through a group policy (the “Policy”) issued by
Lincoln National Life Insurance Company, the Policy's
insurer and claims administrator. See LIN00125-205.
The Policy is subject to ERISA. See, e.g., LIN00140.
seeking long-term disability benefits must first show that
they meet the Policy's definition of
“disabled.” LIN000150. If an insured is disabled
primarily because of certain “Specified Injuries or
Sicknesses, ” then benefits are limited to 24 months.
LIN000157. One such illness is “Chronic Fatigue
Sickness, ” “a sickness that is characterized by
a debilitating fatigue, in the absence of other known medical
or psychological conditions. It includes, but is not limited
to . . . chronic fatigue syndrome . . . .” Id.
2013, Mr. Loucka sought treatment for fatigue, joint pain,
and muscle soreness. That May he tested negative for Lyme
disease and his metabolic screening panel came back normal.
See LIN00621. Mr. Loucka was tested again in
November 2013. See LIN05157-60. That test was also
negative for Lyme disease. Id. Still, he sought
treatment from Dr. Joseph Jemsek, whose clinic specializes in
Lyme disease treatment. See LIN09169. During their
initial meeting, Mr. Loucka told Dr. Jemsek that he had
“had extensive exposure to ticks” and had found
ticks on him, “but [they] never attached.”
Id. He also reported that he began noticing symptoms
in February 2013 “with the onset of fatigue” and
that only three months later he “notic[ed] excessive
Jemsek ordered another round of blood testing, and a private
laboratory called IGeneX conducted IgM and IgG Western Blot
tests. See LIN07246-47. The IgM and IgG Western Blot
tests are common Lyme disease diagnostic tests. See
Daniel L. Depietropaolo et al., Diagnosis of Lyme
Disease, 72 Am. Fam. Physician 297 (2005) (available at
LIN00816-17, 00432-37). But IGeneX did not conduct an
EIA/ELISA or IFA test, which the Centers for Disease
Control's (“CDC”) two-tiered Lyme diagnostic
procedure requires before any Western Blot testing. LIN00212.
IGeneX also used its own criteria for interpreting the test
results instead of the CDC's. LIN007246-47. Ultimately,
the IgG blot test was negative for the presence of Lyme
disease under both the CDC's and IGeneX's criteria,
and the IgM blot test was negative under the CDC's
criteria but indeterminate under IGeneX's alternative
April 2014, Dr. Jemsek noted that Mr. Loucka was “still
unsure about his Lyme diagnosis.” LIN007140.
Nonetheless, he put Mr. Loucka on an intensive antibiotic
regime, a common treatment for Lyme disease. See
LIN00210-13. Even with antibiotics Mr. Loucka's symptoms
persisted: he reported “increased neuropathy;”
“increased anxiety, [joint] pain . . ., paresthesia
in the face and brain, as well as ‘body
tenderness;” and “increased arthralgias and . . .
lower back pain.” LIN007142. After Mr. Loucka began
antibiotic treatments, IGeneX tested Mr. Loucka's liver
tissue looking for evidence of DNA from the bacterium that
cause Lyme disease. LIN07243-44. The tests were negative for
bacterial DNA. Id.
that year a psychologist, internal medicine doctor, and
infectious disease specialist at the Mayo Clinic evaluated
Mr. Loucka and suggested he had “CFS and GAD
[Generalized Anxiety Disorder].” LIN007146. By
September, after several months of antibiotics, Mr. Loucka
continued to have “some ambivalence [about] whether he
truly ha[d] tickborne illness, ” because he “had
not seen the improvement he was hoping for” despite
intensive treatment. Id. His condition was
“only maintaining, maybe even slowly worsening.”
Id. Indeed, “[h]e continue[d] to have waves of
fatigue, increasing lightheadedness, moodiness, full body
agitation, brain tingling.” Id. But Dr. Jemsek
continued to prescribe intensive antibiotic treatments, even
though Mr. Loucka reported “no real clinical
progress” and he “[wa]s not responding well to
Mr. Loucka filed a claim for long-term disability benefits,
LIN15204-15, and he included with his application a
functional capacity assessment from Dr. Jemsek. He diagnosed
Mr. Loucka with “Lyme borreliosis complex, a chronic,
multisystemic, inflammatory illness.” LIN15216.
Lincoln's experts disagreed. Dr. Gary Greenhood, who is
board certified in internal medicine and infectious disease,
reviewed Mr. Loucka's claim and found that Mr. Loucka was
impaired. LIN00014-15. But Dr. Greenhood warned that the
evidence “does not support that the claimant has Lyme
disease. In addition to no report of a first tier test to
Lyme disease, both IgM and IgG Western Blot tests are
negative by CDC . . . criteria.” Id. After Mr.
Loucka submitted additional material, Dr. Greenhood conducted
a supplemental review, but he maintained that Lyme disease
was unsupported. See LIN00035. He instead concluded
that “the likely diagnosis is Chronic Fatigue
Kent Crossley, who is board-certified in internal medicine
and infectious disease, also reviewed Loucka's medical
records for Lincoln. While quibbling with Dr. Greenhood's
conclusion on impairment, he also found “no evidence of
any infectious process including Lyme disease.”
LIN02301. Dr. Crossley noted that Mr. Loucka's physical
limitations were “entirely self-reported” and
that “Western Blot testing was done in February 2014
and was negative.” LIN02300. Dr. Crossley agreed that
Mr. Loucka's symptoms “support a diagnosis of
Chronic Fatigue Syndrome.” LIN2301.
the differing opinions with respect to impairment,
Lincoln's claim examiner approved Mr. Loucka's claim
for long-term disability, effective as of October 5, 2014.
LIN14842. But because Mr. Loucka was found to be disabled due
to CFS, the claims examiner explained that the Policy
“limits benefits to 24 months for the condition causing
[Mr. Loucka's] disability.” LIN14843. In April
2016, Lincoln sent a letter to Mr. Loucka reminding him of
the Policy's 24-month benefits limitation and informing
him that his ...