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Loucka v. Lincoln Nat'l Life Ins. Co.

United States District Court, District of Columbia

November 7, 2018




         This 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.


         Wesley 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.

         Insureds 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.


         In 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 fatigue.” Id.

         Dr. 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 criteria. Id.

         In 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 agitation;'” “gastrointestinal 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.

         Later 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 therapy.” LIN07150.


         Ultimately, 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 Syndrome.” Id.

         Dr. 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.

         Despite 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 ...

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