A Federal Court in an ERISA Long Term Disability denial case doesn’t believe an alleged phone call between a doctor hired by the LTD insurance company, and the treating doctor actually happened in the way their doctor claims it did.
The disabled worker, claimant Nancy Hart, was receiving disability benefits for 8 years, before it was terminated by Unum. Unum then terminated her benefits claiming she no longer met the definition of disability. The court disagreed, and decided she was disabled, that Unum improperly terminated her long term disability benefits, and that they owed her past benefits and future.
Prior finding of disability is significant for ERISA LTD cases
Courts consider past findings of disability or past payments of disability benefits to weigh against the insurer unless something new and significant changes their decision.
What this means is, if you were previously found disabled, and/or were receiving benefits for the disability, your insurer needs to provide something new and significant in order to justify terminating your benefits.
This significant change can’t just merely be a stabilization of your condition. In other words, let’s say your spine/back was degenerative, and you were found to be disabled. New tests and exams reveal the degeneration halted, but it did not improve. This is not significant enough to justify a termination of your benefits.
Report of alleged phone call between LTD insurance doctor and treating doctor was not credible
The doctor hired by the LTD insurance company alleged he called the claimant’s doctor, and in that phone call he asked the claimant’s treating doctor if she “felt Ms. Hart was medically precluded from engaging in full time primarily seated work activities.”
The insurance company’s doctor then alleged the treating doctor said ““she did not know and had no opinion.” The insurance company’s doctor further alleged the treating doctor then recommended an independent medical exam, and without that, she would no opinion on the claimant’s disability and ability to work.
The court found this report lacked credibility. The report of her statements contradicted years of her treatment reports, notes and findings.
Insurance company hires doctor to perform medical exam that didn’t sufficiently weigh prior MRI studies
Insurance companies regularly hire their own doctors to examine their claimants. Then they perform what is called an “Independent Medical Exam” which is anything independent. Their doctors will regularly spin any evidence and findings, as well ignoring compelling medical evidence to support the insurance company’s position.
In this case, their doctor noted limitations in what the claimant Hart could endure. More significantly, the doctor seemed to ignore or insufficiently consider prior MRI’s which support the claimant’s disability.
The doctor also ignored claimant’s subjective reports of pain
The 9th Circuit, which covers California, states your subjective complaints of pain must be considered and not ignored. The court was not convinced a 25 minute examination by an insurance company doctor can negate years of reports of pain by the claimant.
Greater weight is given to doctors who examine the LTD claimant vs those who just review files
The insurance company hired several doctors to work for them. Two of them only reviewed files, and never examined the claimant. Their opinions are accorded less weight because of this.
San Diego ERISA Long Term Disability Lawyer
While I did not handle this case, and this is just a summary of a disability case, if Unum or any other company denied or terminated your benefits, call us right now, or complete the contact form on my website.Hart v. Unum