Lambert Coffin
Integrity. Experience. Law.


S/He Didn’t Examine Me May Not Be Enough Under ERISA

Claimants of ERISA disability benefits are often confused regarding why the insurance company rejected the opinions of his/her treating physicians in favor of opinions of physicians who simply reviewed medical records but never examined the claimant and who rejected the opinions of the claimant’s treating physicians.  It’s the function of the deference generally afforded to the insurance company’s review and decision.

In analyzing some of the advantages associated with such deferential review, SCOTUS has held that insurers are not obligated to defer to treating physicians, who know and examine the claimant, over that of reviewing physicians, who merely review medical records and render an opinion.  See Black & Decker Disability Plan v. Nord, 538 U.S. 822 (2003) (holding that ERISA does not require plan administrators to accord special deference to opinions of treating physicians).

Since Nord, courts for the most part have held that a mere disagreement between treating physicians and reviewing physicians is insufficient to establish arbitrary and capricious decision-making.  Take this quote from a recent case in the District of Puerto Rico as a prime example of this:

The Court agrees with MetLife, see ECF No. 131 at 45-49, that, under circuit precedent, these record-based “findings by [the] independent medical examiner[s] g[i]ve MetLife the requisite `substantial evidentiary grounds for a reasonable decision in its favor.’” Medina, 588 F.3d at 46 (quoting Denmark v. Liberty Life Assurance Co. of Bos., 566 F.3d 1, 6 (1st Cir. 1999)); see also Gannon v. Metro. Life Ins. Co., 360 F.3d 211, 216 (1st Cir. 2004) (affirming that a court may uphold an administrator’s “termination of disability benefits [where] the supporting medical evidence consist[s] solely of an independent medical consultant’s review of the claimant’s file, which include[s] records from the claimant’s physicians.”) (citing Matías-Correa, 345 F.3d at 9-10, 12). That Drs. Simon and Cephas “did not physically examine [Santana] does not decrease the credibility of [their] medical opinion” that the record fails to support Santana’s entitlement to further benefits, which, in turn, “constitutes medical evidence in support of MetLife’s decision to terminate [Santana’s] benefits.” Id. at 214. Although the record shows that Santana’s personal doctors had diagnosed him with several disorders, “ERISA does not require plan administrators or reviewing courts to accord special deference to the opinions of treating physicians.” Id. at 215 (citing Black & Decker Disability Plan v. Nord, 538 U.S. 822 (2003)). Under the terms of the Plan, it was within MetLife’s discretion to weigh that competing evidence to determine whether Santana was `disabled’ and hence whether he was entitled to continuing benefits. “And in the presence of conflicting evidence, it is entirely appropriate for [the Court] to uphold the decision of the entity entitled to exercise its discretion.” Id. at 216. Accordingly, the Court hereby finds that MetLife acted reasonably and within its discretion, in light of the evidence before it, when it denied long-term disability benefits to Santana and then upheld that decision on appeal.
— Santana-Diaz v. Metro. Life Ins. Co., 13-cv-1628, (D.P.R. Mar. 29, 2017).

The moral of this story is that you must provide as much proof of disability as possible.  Relying on unsupported statements by your treating physician, in certain instances, won’t suffice.

Here’s a link to the Santana-Diaz decision.

Andrew Davis