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 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.