Treating Physician Reports in ERISA Claims

April 25, 2012

Treating Physician Reports in ERISA Claims Under Seventh Circuit case law, information provided from the treating physicians in ERISA claims is likely superior to the information generated by an insurer's medical consultant, especially in a case where the consultant does not conduct a physical examination. Hawkins v. First Union Corporation Long Term Disability Plan, 326 F.3d 914, 917 (7th Cir. 2003), citing Bali v. Blue Cross & Blue Shield Ass'n, 873 F.2d 1043, 1048 (7th Cir. 1989); cf. Whitson v. Finch, 437 F.2d 728, 732 (6th Cir. 1971). Although an ERISA plan administrator may give weight to doctors who only do a medical record review, the Seventh Circuit recently held that a plan administrator's reliance on record-reviewing doctors who selectively criticize the overwhelming evidence provided by treating physicians is part of "a larger pattern of arbitrary and capricious decision-making." Holmstrom v. Metropolitan Life Ins. Co., 615 F.3d 758, 775 (7th Cir. 2010); see also Love v. Nat'l City Corp. Welfare Benefit Plan, 574 F.3d 392, 396-97 (7th Cir. 2009) (denial of benefits was arbitrary where "neither [denial] letter explained why the reviewer chose to discredit the evaluations and conclusions of Love's treating physicians" and "every doctor that personally examined Love concluded that she was unable to work") and Demaree v. Life Ins. Co. of North America, ---F.Supp.2d--- (S.D.Ind. June 1, 2011) (The decision to reject the opinion of a treating physician must have some rational basis).

In evaluating a claim for disability benefits, an insurer or plan administrator may also not summarily reject a treating physicians' opinion in favor of the opinion of its own consulting physicians without sufficient reason for doing so and an explanation to the claimant. Hackett v. Xerox Corp. Long-Term Disability Income Plan, 315 F.3d 771, 775 (7th Cir. 2003) ("Conclusions without explanation do not provide the requisite reasoning and do not allow for effective review."); see also Leger v. Tribune Co. Long Term Disability Plan, 557 F.3d 823, 823 (7th Cir. 2009) (rejecting, without explanation, important aspects of evidence presented by a claimant is an abuse of discretion). The Seventh Circuit explicitly requires ERISA plan administrators to provide claimants with an explanation as to why critical, supportive medical evidence is rejected. Halpin v. W.W. Grainger, Inc., 962 F.2d 685, 695 (7th Cir. 1992) ("[T]he reasons for rejecting evidence must be articulated if there is to be meaningful appellate review."). Moreover, plan administrators may not "arbitrarily refuse to credit a claimant's reliable evidence, including the opinions of a treating physician." Black & Decker Disability Plan v. Nord, 538 U.S. 822, 834 (2003) (emphasis added). The Supreme Court in Nord recognized that "treating physicians, as a rule, have a greater opportunity than consultants to know and observe the patient as an individual." Id. at 832.

An insurer or plan administrator's selective readings of the evidence that are not consistent with the entire picture is a hallmark of an unreasonable determination. Holmstrom, 615 F.3d at 777; see also Majeski v. Metropolitan Life Ins. Co., 590 F.3d 478, 483-84 (7th Cir. 2009) (holding that denial decision was arbitrary where insurer selectively relied on pieces of evidence to support denial of benefits, while that evidence in context demonstrated disability); Leger, 557 F.3d at 832-33 (denial decision was arbitrary where insurer "cherry-picked the statements from her medical history that supported the decision to determine her benefits, while ignoring a wealth of evidence to support her claim that she was totally disabled"). A determination to terminate or deny disability benefits will not be deemed reasonable unless the plan administrator or insurer gives sufficient weight to the treating physicians' opinion regarding his or her patient's functionality.