Many claimants are shocked and upset when they receive a denial or termination of their long-term disability benefits based on some doctor’s opinions, who happens to live in another state, has never examined them nor ever had a conversation with them when their own treating physicians who have known and treated them for years supports their inability to work. Shouldn’t their own treating physician’s opinions hold more credibility over some random doctor who provides a biased records review for an insurance company? The Sixth Circuit Court of Appeals says “yes” in some circumstances the treating doctors opinions should carry more weight. The following is a case that did not involve the law firm of Dell & Schaefer, however it is a good example of how insurance companies cannot always get away with denying claims based solely on paper reviews.
The Plaintiff, James Neaton appealed a Tennessee District Court’s Decision to uphold their termination of his long-term disability benefits for which he was covered by virtue of his employment with Navy Federal Credit Union. Neaton stopped working due to a diagnosis of a rare disease called Gorlin’s Syndrome which causes the development of numerous basal-cell carcinomas which are prone to metastasizing and have to be surgically removed. Neaton underwent several surgeries and required several more and could no longer handle the material and substantial duties of his occupation due to the lengthy recovery periods after each surgery. As he gets older, he requires more and more surgeries as this disease is progressive. At times he required removal of 20 cancer lesion during one procedure which caused tremendous pain, stress and anxiety. His treating physician put him off work and ordered him to avoid sunlight and fluorescent lighting which would make it impossible for him to work in a home or an office environment.
Hartford’s Hired Physician Renders Opinion That Claimant Can Work From Home In a Full-Time Sedentary Capacity Even If He Undergoes Surgery Once A Month for the Remainder of His Lifetime
Hartford originally approved his claim since they agreed that he could not commute to work as he would be exposed to sunlight. Neaton continued to undergo surgeries and required several Moh’s surgeries which each required 3-4 months of recovery time. After paying his benefits for seven months, Hartford terminated Neaton’s benefits claiming that he was capable of performing an indoor sedentary job relying on a peer review physician who never examined or even spoke to Neaton, but just reviewed his medical records and came to his own conclusions.
During the appeals process, Neaton underwent several more surgeries and endured painful and lengthy recoveries. The peer review physician opined that even with the necessity of several surgeries every month, a week off to recover would be ample. If he were working from home, 3-4 days off after surgery would be adequate for reasonable healing. This opinion was rendered without ever examining or speaking to Neaton. Hartford upheld its decision to terminate Neaton’s benefits and Neaton then filed suit.
Court of Appeals Holds Hartford’s Peer Review Physician Opinion Lacks Credibility For Failure to Examine Claimant
Hartford’s hired peer-review physician rendered his opinion that Neaton was capable of working in his own occupation from home without examining him. According to the Court, a patient’s recovery time following surgery is variable and depends in part on the extent of a patient’s pain. As such, the length of a patient’s recovery time is in large part a credibility determination. Whether a doctor has physically examined the claimant is a factor that may be considered in determining whether a plan administrator acted arbitrarily in giving weight to the opinion of its consulting physician. The Sixth Circuit has held that the plan administrator’s failure to require a physical examination “may in some cases, raise questions about the thoroughness and accuracy of the benefits determination.” The Court found that Hartford’s in-house opinion was conclusory as he failed to even speak to Neaton about his recover process after each of his many surgeries. Over the past 16 month he has required 12 total surgeries which could reasonable require him to miss over 35 days of work during that time period. In some circumstances, a paper review can be relied on to determine whether a claimant is capable of returning to work. However, in this case the court disagreed with Hartford’s analysis and held that Neaton’s treating physician’s opinions and not the opinions of Hartford’s peer review physicians held more credibility.
Hartford failed to (1) provide supported evidence that, if working from home, Neaton could recover from Moh’s surgery in 3-4 days; (2) failed to accurately calculate the frequency of his surgeries and work absences; and (3) relied on the opinion of an in-house vocational expert who cited no evidence in claiming that his employer could accommodate his high rate of absenteeism. Accordingly, the court held that Hartford’s determination was arbitrary and capricious.
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