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Are the opinions of your treating physician’s entitled to more deference?

Attorney Victor PeñaAuthor: Attorney Victor Peña

The short answer, as you may have already learned, is no. Under ERISA, the opinions of treating physicians, despite the physicians often having the closest contact with the patient/claimant under review, despite arguably having the most “accurate” medical information on the claimant and despite being perhaps the only physicians who have had the chance to actually meet the claimant in person and so arguably the physicians in the best position to say whether their patient is unable to work are not entitled to special deference. In fact, ERISA allows a disability insurer or the claims administrator reviewing an ERISA claim to rely instead on the opinions of internal physicians working for them who often only conduct medical “file reviews” and may never actually meet the claimant in person.

However, in a recent opinion out of the Western District of Michigan the Court explained that although a treating physician’s opinion is not dispositive by any means, a disability insurer must substantively consider such an opinion and factually distinguish it if denying the claim. In other words, the insurer may ignore the treating physician’s opinion but has to explain why and give a good reason for doing so.

In Vochaska v. Metlife, Dr. Liscow made clear his opinion that his patient, Vochaska, could not work full-time due to post-concussion symptoms, such as sensitivity to light and sound, nausea, and headaches.

Although the conditions on which Dr. Liscow’s opinion was based consistently appeared in the records submitted by Dr. Liscow, and were cited by Vochaska in his application for disability, MetLife, in denying Vochastka’s claim, ignored them and did not discuss the conditions except to state that it had “not received medical to support [Vochaska’s] complaints of a physical impairment due to headaches [and] light and sound sensitivity.”

MetLife assigned the file review to a psychologist whose medical expertise would not permit her to comment on “non-psych medical regarding any possible impairments due to light and sound sensitivity or headaches.”

On appeal, although MetLife had two additional internal physicians perform file reviews, neither report offered any insight into the conditions upon which Dr. Liscow based his opinion that Vochaska was disabled. Neither physician even attempted to explain why he or she reached a different conclusion from Dr. Liscow.

As the court explained, “MetLife was not required to accept Dr. Liscow’s opinion, but it could not reject it without reason.” MetLife’s failure to provide reasons for adopting an alternative opinion helped the court conclude that MetLife had abused its discretion.

Although the court did not ultimately find that the record clearly established Vochaska was disabled and instead remanded the case for further evaluation, the opinion is nevertheless a “win” for ERISA disability claimants.

This case is a reminder that disability insurers review claims with the ultimate goal of denying the claim in hopes that the claimant will not fight back. So it is not surprising when an insurer disregards the opinion of a physician supporting a finding of disability. But if a disability insurer chooses to ignore a treating physician’s opinion it must provide reasons for doing so and factually distinguish that doctor’s opinion from its reviewing physicians.

It is important to also remember that the mere opinion of your treating physician that you are disabled will not be enough to combat a disability insurer’s ultimate goal of denying the claim.



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