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How to Consider Long-Term Disability Insurers’ File Review Medical Opinions

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How to Consider Long-Term Disability Insurers’ File Review Medical Opinions

07 Apr, 2021
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Chicagoans with long-term disability insurance coverage through an ERISA-governed disability plan often are perplexed by how an insurer’s doctors who never examined the client can disagree with their treating doctors. There is nothing per se wrong with an insurer asking doctors to review medical records and provide an opinion on a claimant’s functionality without ever examining the claimant. In some cases, a doctor is just as capable of rendering an opinion based on a file review as a doctor who examines the claimant. In other cases, a file-only review can harbor over-representing the claimant’s capabilities, especially where the claimant is still being evaluated for the complete set of causes of the symptoms. The degree to which the insurer can rely on those file-only reviewing doctors is also influenced by the standard of review of the case (de novo or deferential). For background on the standard of review, see this prior article.

In Withers v. United of Omaha Life Insurance Co., No. 1:19-cv-108, 2021 WL 1062551 (W.D. Ky. Mar. 19, 2021), Withers had a number of symptoms and was actively undergoing workup for which illnesses caused which symptoms. After a long and complex medical investigation by treating doctors, Withers was finally diagnosed with Parkinson’s disease, among many other illnesses. United of Omaha (a/k/a Mutual of Omaha) discounted the treating doctors’ opinions, as the Parkinson’s symptoms intensified over time, so earlier records did not document the tremors as much as later records.

Under a de novo standard of review under ERISA § 502(a), the court did not consider United of Omaha’s conflict of interest, but it was able to consider the bias, interest, or motive of the physicians hired by the insurer to affect their credibility. The file-only reviewing doctors did not even consider any of Withers’ job duties, or that Withers was awarded Social Security Disability benefits. After weighing these credibility concerns under Federal Rule of Evidence 607, the court held that United of Omaha improperly denied Withers long-term disability benefits.

If your long-term disability claim has been denied by the insurance company based on opinions of doctors who never examined you, consult a knowledgeable ERISA long-term disability lawyer immediately. You have a limited amount of time to challenge the decision.

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