Employees in Chicago with claims for long-term disability insurance benefits frequently ask how an insurer can deny their claim or terminate benefits if their doctor certifies they are disabled. After all, your doctors are most familiar with your treatment history and symptoms. The degree of weight your doctor’s opinion receives from the insurer often depends on the judicial standard of review that applies. For a good discussion of standard of review, see our past post here. Under the deferential, or arbitrary and capricious standard of review, a court will not weigh the evidence, but will determine whether a reasonable person could have come to the same conclusion as the insurer. So insurers have some discretion in choosing which opinion to credit where there a medical consultant disagrees with your doctor. The key to success in these cases then is to identify any flaws in reasoning of the insurer’s medical consultant so a court can hold it was not reasonable to rely on that medical consultant’s opinion. In a recent case, a person receiving long-term disability benefits fell short of clearing that hurdle.
In Elias v. Unum Life Ins. Co. of Am., No. 21-cv-1813, 2023 WL 375649 (D. Minn. Jan. 24, 2023), Unum approved Elias’s claim for long-term disability in 2008. He remained on claim until Unum terminated his benefits in 2021. Elias sued for benefits under ERISA § 502(a), raising several arguments, though the court rejected each of them.
Elias argued Unum should not have relied on paper medical reviewers over the opinions of his doctors who treated him, but the court reasoned nothing under deferential review requires the insurer to accept the opinions of treating doctors over those of its consultants. Elias argued there was no evidence his condition improved during the 13 years he received benefits, but the court found Unum had pointed to evidence of improvement in his condition between 2016 and 2021. He also argued Unum violated the claims procedure regulations, 29 C.F.R. § 2560.503-1, by failing to allow him an opportunity to address new evidence before finalizing its decision. The court disagreed, finding because Elias’s claim began before 2018, his claim was not subject to the new 2018 regulations.
If you have a claim for long-term disability benefits denied or terminated, talk to a skilled long-term disability attorney about how to best fight that denial or termination.