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

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.

Leave a comment or ask us a question

Questions About Hiring Us

Do you work in my state?

Yes. We are a national disability insurance law firm that is available to represent you regardless of where you live in the United States. We have partner lawyers in every state and we have filed lawsuits in most federal courts nationwide. Our disability lawyers represent disability claimants at all stages of a claim for disability insurance benefits. There is nothing that our lawyers have not seen in the disability insurance world.

What are your fees?

Since we represent disability insurance claimants at different stages of a disability insurance claim we offer a variety of different fee options. We understand that claimants living on disability insurance benefits have a limited source of income; therefore we always try to work with the claimant to make our attorney fees as affordable as possible.

The three available fee options are a contingency fee agreement (no attorney fee or cost unless we make a recovery), hourly fee or fixed flat rate.

In every case we provide each client with a written fee agreement detailing the terms and conditions. We always offer a free initial phone consultation and we appreciate the opportunity to work with you in obtaining payment of your disability insurance benefits.

Do I have to come to your office to work with your law firm?

No. For purposes of efficiency and to reduce expenses for our clients we have found that 99% of our clients prefer to communicate via telephone, e-mail, fax, GoToMeeting.com sessions, or Skype. If you prefer an initial in-person meeting please let us know. A disability company will never require you to come to their office and similarly we are set up so that we handle your entire claim without the need for you to come to our office.

How can I contact you?

When you call us during normal business hours you will immediately speak with a disability attorney. We can be reached at 800-682-8331 or by email. Lawyer and staff must return all client calls same day. Client emails are usually replied to within the same business day and seem to be the preferred and most efficient method of communication for most clients.

Dell & Schaefer Client Reviews   *****

Patrick J.

My experience with Dell & Schaefer began after a prolonged and frustrating experience with my disability carrier subsequent to contracting an illness which left me incapacitated. As a few examples of the frustration I am referencing: I had been accused by the ‘doctors’ appointed by my carrier to review my case as being a narcissistic fraud; the carrier sent a man to my home in the country unannounced to interview me (while I was not there but my wife and small children were); the carrier seemed to be fighting my doctor’s diagnosis and statement regarding my disability and illness; the carrier was not communicating well with me and was being cryptic with responses to legitimate questions.

I finally was so stressed from what should have been a simple process, and exhausted from the emotional and mental toll of filing a claim, that I was about to give up in the interest of maintaining what little health I had left and not wasting it fighting my carrier. I reached out to Greg Dell and he immediately set up a time to talk with Stephen Jessup and himself. I told them I just couldn’t keep managing the process – that the fight was taking its toll and I was inclined to either ‘tap out’ or quit altogether. After reviewing my case they were more than happy to drive their tank into the battle which I had been fighting with a handgun (Mr. Dell’s example). I signed with Dell & Schaefer, and suffice it to say this ‘tank’ comment seems to have been true as the very same day my carrier received the letter from Dell & Schaefer saying I had engaged their services is the same day my claim was approved.

I was curious to see how service would be after they had me contractually obligated to them. I have been impressed on this front as well. Every effort to correspond receives a response within 24 hours. Mr. Jessup is my primary contact and I have received more than one personal note from him encouraging me as I battle my illness; I believe that he really does care beyond just the financial interest the firm has in my case. On the business side of my interaction with them, I have been impressed with the thoroughness and timeliness of all responses – no matter how unimportant they might seem to Mr. Jessup. On the occasion when a question is more administrative in nature and Mr. Jessup or Mr. Dell need to defer to one of their staff, the staff is equally as timely and thorough and professional in their responses.

The stress and frustration of dealing with my carrier are gone; this benefit in and of itself is priceless. To add, I feel the benefit I gain from having Dell & Schaefer as my advocates makes their fees seem to be an excellent value.

***** 5 stars based on 202 reviews

Speak With An Attorney Now

Request a free legal consultation: Call 800-682-8331 or Email Us