Employees living in Chicago and throughout Illinois who have a long-term disability insurance claim denied often read the denial letter in disbelief, wondering how the insurer could deny their claim based on medical opinions by doctors who never even examined them. Often, these medical opinions by so-called “peer reviewers” disagree with your treating doctors’ opinions, and occasionally the file-reviewers attempted to merely speak to your doctors. For a good discussion of a doctor’s view on “peer reviews,” see “Dear Insurance Doctor, You Are Not My Peer.” Though the denial letter represents the insurer relied on this opinion, the truth is the denial letter is just the insurer’s representation of the evidence. It is not a substitute for evaluating what basis the insurer had to deny the claim, which is best left to a long-term disability insurance lawyer.
In Miller v. PNC Financial Services Group, Inc., No. 16-25142, 2017 U.S. Dist. LEXIS 162230 (S.D. Fla. Oct. 2, 2017), the PNC long-term disability plan administrator, Liberty Mutual Life Insurance Company, denied Miller’s claim. She suffered from back pain and radiculopathy, and had trouble sitting for any length of time. Liberty determined Miller’s occupation of branch manager was a light exertion occupation, but could also be performed at the sedentary level. When denying the claim, Liberty sought a medical opinion from Dr. Negin Gohari, who told Liberty that Miller could only sit a total of 3 hours per day, but also that Plaintiff could work full-time at the sedentary exertion level. Liberty asked Dr. Gohari to clarify his opinion, because working full-time at sedentary level required sitting “most if not all of the day.” Dr. Gohari then modified his opinion and stated Miller could sit 7 hours per day. The denial letter only stated that Dr. Gohari opinion Miller could sit 7 hours per day. After Miller sued to recover her long-term disability benefits under ERISA § 502(a), the court ultimately thought the change in Dr. Gohari’s opinion upon the insurance company’s prompting was persuasive evidence Miller could not work full-time at the sedentary level.
I have encountered several instances similar to this while representing clients. You really cannot tell if the insurer had a solid basis to deny your claim until probing through its files and communications. If your claim for long-term disability insurance has been denied, waste no time in contacting an experienced ERISA long-term disability insurance lawyer.