A common question we receive is, How can an insurance company rely on their own doctors over the opinions of treating physicians? Or, How can an insurance company rely on doctors who merely review a paper file and never see the claimant in person?
Unfortunately, insurance companies are allowed to do this as long as they have a good reason for doing so. If the insurance company’s doctor’s opinion is different from your treating physician they have to provide a good reason why. To seem reasonable, the insurance company will often require its hired doctor to perform a peer review by reaching out to the treating physician and discussing the claimant’s condition.
That is what happened in a recent case out of Indiana involving Aetna Life Insurance Company. Upon review by an Indiana Federal District Court, several errors were found when a judge reviewed Aetna’s decision. The case involved an Amazon Employee who claimed she was unable to work due to severe urinary incontinence.
Despite undergoing surgery and multiple Botox injections she suffered from uncontrollable urinary incontinence and her doctor certified her disability. Despite the evidence submitted, a nurse reviewer deemed the evidence insufficient and the claim was denied. On appeal, Aetna obtained a physician review and upheld its denial based on an alleged conversation the reviewing doctor had with one of the treating doctors.
Following the decision, the claimant wrote to Aetna, challenging its use of the conversation with a doctor who was not the one certifying disability, which the court deemed a part of the record.
In court, it was argued that Aetna’s doctor had falsely stated that further surgery was not recommended, that Aetna failed to consider all of the medical evidence and that the opinions of the doctor who certified her disability were rejected without any discussion.
The evidence showed plaintiff’s condition was not improving and symptoms were reported as “severe and persistent” yet Aetna’s reviewing doctor’s opinions were based on his faulty assumption that invasive treatment was not being considered.
On review, the court was troubled with Aetna’s disregard of plaintiff’s primary physician and criticized Aetna for failing to provide a reasonable explanation for disregarding the doctor’s opinions. The court also pointed out Aetna’s mischaracterization of doctor’s notes describing surgeries as “uncomplicated.” The court observed that “such findings indicated only that the surgery went as expected—not, as Aetna seemed to suggest, that they remedied the claimant’s conditions. The same is true with the “normal” observations made in some medical opinions.”
Finding Aetna’s file review clearly biased, the court remanded the case back to Aetna. Despite its grossly inadequate assessment of a severe claim Aetna was not ordered to reinstate the claim. Given the level of procedural and substantive violations the court should have awarded benefits to this claimant outright without giving Aetna the opportunity to deny the claim again.
This case is a perfect example of what a “win” can represent for claimants with even severe conditions when dealing with ERISA. Although the court found Aetna’s decision was wrong and unreasonable it did not award benefits to the claimant but instead gave Aetna another opportunity to perform further mischief.
This case was not handled by our office, but it may provide claimants guidance in their pursuit of disability benefits. If you need assistance with a similar matter please contact any of our lawyers for a free consultation.