DATE POSTED 15. 12. 2015, By

Treating Doctors’ Opinions Are More Reliable than Insurance Doctors’ Opinions in Long Term Disability Case

Many employees seeking long term disability benefits from their employer, union trust fund, or insurance company are under the care of multiple different physicians and specialists. There is no magic number as to how many physicians one must have in order to get approved for long-term disability benefits. Sometimes a claimant has one physician with whom they have built a relationship and received all of their treatment. Other claimants will have 15 different specialists because they have endured misdiagnoses, required tertiary care (e.g. at Mayo Clinic), or they have different co-morbidities that require various areas of expertise. Though the number of physicians a claimant has should not dictate the processing of a disability claim, insurers will often utilize multiple non-examining consulting physicians and nurses to counter the opinions of multiple treating physicians. Historically, insurer’s consulting physicians’ opinions are neither as thorough nor accurate as treating nurses’ or physician’s opinions.

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In a recent case, a customer-project manager for Hewlett-Packard Company, Donald Godmar, challenged the insurer’s reliance on three different non-examining file reviews by consulting physicians. Godmar v. Hewlett-Packard Co., No. 15-2480, 2015 U.S. LEXIS 21467 (6th Cir. Dec. 9, 2015). The Court in this case found that in relying on the consulting physicians’ opinions, the insurer had improperly dismissed Godmar’s limitations as subjective and failed to consider various parts of Godmar’s medical makeup.  One of the insurer’s conclusions that was rejected by the Court was that Godmar’s consistent reports of pain with corroborating diagnoses by his treating physicians were inherently subjective and unreliable. The Court was not persuaded by this conclusion, because as it had stated in multiple other cases, making “credibility findings concerning [the claimant’s] pain without the benefit of a physical exam” would “support the finding that [the administrator’s] determination was arbitrary.” Id. at *25; citing Smith v. Cont’l Cas. Co. 450 F.3d 253, 264 (6th Cir. 2006).  Here, the insurer waived its opportunity to have an independent physician examine Godmar.  In addition to failing to accept Godmar’s pattern of reported pain as credible evidence supporting disability, the insurer also concluded that there was no objective evidence preventing Godmar from working, prior to him being confined in a recovery center. But, the consulting physicians and insurer totally ignored that Godmar’s job requirements—namely that he was required to drive to his work-site on a daily basis—which he could not do because was on a heavy regimen of morphine.  As result of these poor consulting physician opinions, the quality of Godmar’s treating physician’s clinical impressions carried the day.  Godmar was awarded partial disability benefits and Godmar’s remaining benefits claim was to be afforded a new full and fair review by the insurer.

If an insurance company has challenged the credibility of your pain, ignored your medication regimen, or rejected your treating physician’s impressions without examining you, call an experienced ERISA attorney today.

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