Employees in Chicago whose long-term disability insurance claims were denied often have a common frustration. The insurer denied the claim based on the opinion of a doctor who reviewed your medical records, but never examined you, and came to a completely opposite conclusion from your doctors. Your doctors see you and know you, and they can tell you are not exaggerating. The insurer may even provide you with a copy of the doctor’s opinion, now required by 29 C.F.R. § 2560.503-1(h)(4), which will state at the end the doctor is independent, not paid to reach a particular conclusion, and under no conflict of interest. A few steps can help discredit these opinions.
Ask Your Doctor if the Opinion Follows Generally Accepted Medical Standard of Practice
The first thing to do is determine if the opinion follows generally accepted medical standards of practice. Often insurers hire third party vendors, to subcontract doctors to perform file reviews for insurance companies. The vendors often choose doctors with views hostile to disability claims. This happened recently in Duncan v. Anthem Life Insurance Co., No. 20-cv-767, 2021 WL 1237138 (S.D. Ill. Apr. 2, 2021). Anthem hired Dane Street, who in turn hired Dr. Nicole Barry. Dr. Barry is well known for her views that individuals are not disabled from Fibromyalgia, and Fibromyalgia patients should never have limitations, as treatment should involve more activity, not less.
Research the Vendor Your Insurer Hired
Research which vendor your insurer hired. Many of these vendors only serve insurance companies. Though they describe themselves as independent, they know disability insurers will not hire them if they pick doctors who recommend approving claims.
Research the Reviewing Physician
Try to research what the reviewing physician has done before. If the reviewing physician consistently takes positions that are not generally accepted medical standards of practice, a court may allow you to probe into why the vendor keeps choosing that doctor, and why the insurer keeps relying on that vendor and its choice of doctor. When Duncan sued Anthem under ERISA § 502(a), the court permitted Duncan’s lawyer to take Dr. Barry’s deposition to investigate the conflict of interest, which will likely go a long way to help Duncan’s claim be paid.
If your long-term disability claim has been denied, and you question the reliability of the medical opinion on which it is based, schedule a meeting with a skilled ERISA long-term disability attorney.