Broadspire and Aetna deny long-term disability benefits to manager suffering from fibromyalgia, arthritis and cervical disc disease

The case of Mary Midgett v. Washington Group International Long Term Disability Plan, 561 F.3d 887 (8th Cir. 2009) is a reminder that there are discrepancies in how Federal courts apply the law with regard to the weight of credibility to give to an insured’s treating physicians versus the opinions of doctors hired by the insurance carrier to conduct reviews of medical records only.

Mary Midgett was a contract manager for Washington Group International, and was insured under Washington’s group short term and long term disability policies. The policies were originally administered by Broadspire, and then by Aetna. Ms. Midgett filed for benefits under Washington’s short term disability policy due to a myriad of conditions including degenerative arthritis, fibromyalgia and cervical degenerative disc disease, and osteoporosis.

Ms. Midgett treated with various doctors for her conditions. However, as the Court would point to as grounds to uphold the denial of benefits, many of the medical records from her treating physicians were silent as to an opinion on disability, and Ms. Midgett’s primary treating physician’s records suggested he was uncomfortable classifying her as disabled. Based upon results from nerve conduction studies, MRIs, and peer reviews, Aetna denied her claim for short term disability benefits. Ms. Midgett appealed the denial of benefits and added additional medical records from further physicians. Ms. Midgett’s appeal was once again denied, in part upon the review of the medical records from four more insurance company doctors. Between the initial application, and the final determination, Aetna relied upon no less than eight doctors who reviewed the available medical files, and never physically examined Ms. Midgett.

Following Aetna’s denial of benefits, Ms. Midgett filed a lawsuit for the short term disability benefits. The Court, taking into account Ms. Midgett’s medical records from her treating physicians and the opinions of eight insurance company doctors who only reviewed medical records that Ms. Midgett was not totally disabled, the Court sided in favor of the Insurance carrier. In rendering its opinion, the Court pointed to the Supreme Court decision of Black & Decker Disability Plan v. Nord, which stated an insured’s treating physician’s are not automatically entitled to special weight in disability determinations under ERISA. Ultimately the Court determined denial of Ms. Midgett’s short term disability benefits was supported by substantial evidence, as the opinions of all eight of the reviewing physicians accurately represented her medical records and addressed all the evidence supporting her claim for disability.

Comment: Without strong medical support from a claimant’s treat physician(s), it is almost impossible for a claimant to get approved for long-term disability benefits. A claimant must always be aware of the medical records documented by their treating physician and any documentation that the treating physician sends to the disability carrier. The attending physician statements that disability insurance companies send to claimant’s treating doctors contain open ended questions that allow the disability companies to manipulate the answers in support of claim denial. A claimant should always review the attending physician prior to returning the form to the disability carrier.

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