It Takes More than a Doctor’s Opinion You are Disabled to Qualify for Long-Term Disability Benefits

Employees in Chicago with claims for long-term disability benefits are often puzzled by how difficult it can be to get an insurer to pay, or continue paying, the long-term disability claim. Many believe that if their own doctor attests they are disabled, the insurer will accept the liability and pay the claim. But insurers have vast resources, and employ their own doctors and nurses who will review your records and search for any contrary evidence to be able to justify an opinion you are not disabled. Moreover, they may use outside physician consultants to review your files, or even an Independent Medical Evaluation to examine you. A recent case demonstrates how a claimant did not provide enough evidence for the long-term disability insurer to continue paying benefits.

In Evans v. Life Insurance Co. of North America, No. 2:22-cv-00075-ACA, 2023 WL 3868384 (N.D. Ala. June 7, 2023), Evans suffered an injury on the job while working as a wireline operator, a heavy physical exertion occupation. He had two spine surgeries. The employer’s insurer, MetLife, approved the claim and approved continued disability after the change in definition to any occupation. After the employer switched insurers from MetLife to Life Insurance Company of North America (“LINA”), LINA opened an investigation into the claim. LINA sent Evans for an Independent Medical Evaluation. The IME doctor examined Evans and concluded Evans exaggerated his pain complaints, and stated Evans had highly dramatic and over the top pain behavior. He opined Evans had no restrictions from many types of work. Evans appealed, citing only to his family physician’s opinion he was totally disabled. In reviewing the appeal, LINA consulted two additional file-reviewing physicians, who opined Evans could perform sedentary work. LINA vocational consultant found two occupations at the sedentary exertion level Evans could perform given his education, training, and experience. Evans then sued under ERISA § 502(a).

The United States District Court for the Northern District of Alabama ruled in favor of LINA, denying Evans continued long-term disability benefits. The court reasoned it did not have to given any deference to Evans’ treating doctor’s opinion, and the treating doctor’s opinion was based exclusively on Evans’ own reports of pain and limitations. Meanwhile, LINA’s doctors’ opinion were based on the objective medical evidence, including that the two surgeries were successful. Though Evans had been awarded Social Security Disability Insurance benefits, LINA’s decision was based on more recent evidence than that which was before the Social Security Administrative Law Judge.

To better protect himself from this outcome, Evans could have gotten a functional capacity evaluation, or obtained his own Independent Medical Evaluation to rebut the conclusions of LINA’s IME. If you have a claim for long-term disability benefits, contact a skilled ERISA long-term disability attorney today.