Tips When Your Doctor Gives Erroneous Restrictions and Limitations to the Long-Term Disability Insurer

Employees in Chicago with long-term disability insurance under an employer’s group policy frequently lament that their own doctor gave a statement to the insurance company causing a termination of disability benefits. This is more common than you may think. It often arises in the context of the insurer or a doctor working for the insurer calling your doctor and reporting internally that your doctor agreed with the insurer’s doctor that you have no restrictions. Or it can happen by the insurance company sending a cover letter to your doctor and asking the doctor to sign that the doctor agrees. Here are best courses of action to take when that happens.

Determine Whether the Doctor Is Still Treating You

Often long-term disability insurers will reach out to doctors who no longer treat you. A favorite of theirs is to contact a surgeon that no longer treats you after the surgery. Normally, the surgeon will state you no longer have restrictions, because that means the surgeon was successful. If possible, tell the insurer to contact a doctor who currently treats you to avoid this conflict.

Schedule an Appointment with Your Doctor and Ask About It

This may seem obvious, but the first thing to do is schedule an appointment with the doctor the insurer asserts agreed with the insurer and ask the doctor about the statement. Often the doctor did so unintentionally, or the insurer mischaracterized the doctor’s statement or opinion. You can then get the doctor to submit a revised statement, that the insurer must consider. If the “agreement” is inconsistent with the medical records, and the doctor corrects it, the insurer is required to accept the revision. Recently, an insurer tried to stick with the previous opinion that supported benefit termination.

In Patrick v. Reliance Standard Life Insurance Co., No. 19-2106, 2021 WL 1064098 (D. Del. Mar. 19, 2021), Dr. Patrick was on disability for a decade. When her doctor submitted a statement to Reliance Standard indicating restrictions were gone, Reliance terminated benefits. Dr. Patrick’s doctor submitted a sworn statement of error and revised the restrictions, explaining Dr. Patrick’s shoulder injury permanently made her unable to work as a gastroenterologist. Reliance attempted to maintain its reliance on the prior erroneous statement. After Dr. Patrick sued under ERISA § 502(a), the court held Reliance Standard’s refusal to disregard the error was arbitrary and capricious.

If your long-term disability benefits have been terminated because of your doctor’s statement or opinion to the insurance company, call an experienced long-term disability lawyer to discuss how to approach the appeal.