DATE POSTED 01. 07. 2015, By

Who Reviews the Medical Evidence in a Long Term Disability Insurance Claim?

Most employees in Chicago know that when they seek long-term disability benefits, they must first make a formal claim and support that claim with medical records.  The mystery to employees, which may not arise until after the insurer denies the claim, is who reviewed your evidence.  This information is not always offered to you when you make your claim for disability insurance benefits or even after your claim was denied.  Often, you will not find out who is reviewing your medical information or if they are even qualified to review your type of medical condition, until you send a formal and proper request seeking the identity and background of such persons to the insurer.

An ERISA regulation governing disability claims procedures, 29 CFR § 2560.503-1(h)(3)(iv), does not explicitly contain a requirement that the claimant make such a request.  Instead it states the insurer must “[p]rovide for the identification of medical or vocational experts whose advice was obtained on behalf of the plan in connection with a claimant’s adverse benefit determination, without regard to whether the advice was relied upon in making the benefit determination.”  Despite there being no requirement that the burden be on the claimant to explicitly seek this identifying information, many district courts have nonetheless concluded that a plan with procedures that provide a specific mechanism for the identification of its experts upon request—satisfies the regulation.

Following this trend, a recent district determined that because the Plan provided a procedure for obtaining the identification of health care professionals who were consulted on a long-term disability claim and the plaintiff never requested such identifying information prior to filing her suit—she was not deprived of a “full and fair review.”  Bible v. Parker Hannifin Corp. Benefit Fund, No. 2:14-CV-05, 2015 U.S. Dist. LEXIS 77602, *4-5 (E.D. Tenn. June 16, 2015).  Plaintiff originally made a claim for long-term disability benefits due to severe pain and catastrophic weight loss.  The plaintiff weighed a healthy 170 pounds, and within six months lost 82 pounds, putting her at 88 pounds and also suffered a mild stroke.  Bible v. Parker Hannifin Corp. Benefit Fund., No. 2:14-CV-05, 2015 U.S. Dist. LEXIS 78467, *7 (E.D. Tenn. Mar. 20, 2015).  Liberty initially approved the plaintiff’s claim for disability benefits under the “own occupation” standard.  After that initial two years of receiving long-term disability benefits, the definition of disability changes and a claimant will only continue benefits if she is “unable to perform the essential functions of [her] occupation or any other occupation for which [she is] or could, with minimal training, become qualified.”  After Liberty denied the any occupation benefits, the Plaintiff sued under ERISA § 502(a) to recover the disability benefits.

The plaintiff argued she did not receive a reasonable opportunity for a full and fair review even though Liberty did not explicitly reveal the identity of the Nurse Case Manager who reviewed the medical evidence during the appeals process.  The district court disagreed, essentially indicating it is acceptable to not disclose to a claimant, absent an explicit request, who reviews the medical evidence in rendering a decision on the claimant’s case.   This is troubling, particularly because Plaintiff’s attorneys often find flaws in the insurer’s selected experts objectivity or knowledge base (e.g. inappropriate doctors being used to evaluate conditions far outside their specialty, insurance companies hiring doctors who have a documented track record for repeatedly finding claimants “not disabled” in court, or doctors who receive a majority of their income from rending disability determinations for one insurer).

An experienced disability attorney can help you figure out how to obtain information important to the success of your claim, which an insurer can otherwise hide from you.  If you are in the process of making a claim for long-term disability benefits or are appealing a denial of your claim for long-term disability benefits, contact an experienced disability attorney who can equip you with the tools you need to be successful in your pursuit of your benefits.

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