Janet was a customer service specialist for a major corporation. She loved her job and was good at what she did. One day, Janet started feeling fatigued and groggy. She thought it was a cold and would pass in a few days. Unfortunately, Janet never started feeling better.
Her family doctor ran a few tests. The lab work came back abnormal. Janet was referred to a rheumatologist. This was not just an ordinary rheumatologist – but a board-certified rheumatologist.
The board-certified rheumatologist eventually diagnosed Janet with lupus.
By this point, Janet’s fatigue was severe and she suffered from extreme morning stiffness. Now, she did have some good days but she suffered bad days as well.
Janet, being a responsible worker looking out for herself and taking full advantage of the benefits her employer offered, had elected to participate in the long-term disability plan offered by her company. The long-term disability plan was underwritten by a major long-term disability insurance company. Janet believed that given her diagnosis and on-going problems, she would be treated fairly and receive the benefits she paid for with her hard work.
Upon receiving Janet’s disability application, the insurance company began its investigation. The investigation included obtaining Janet’s medical records, conducting video surveillance on Janet, and having its own doctor review the records and give a decision on Janet’s ability.
In support of her claim, Janet’s board-certified rheumatologist provided a statement outlining Janet’s diagnosis, her fatigue and stiffness, and noting that Janet would experience both good days and bad days from her lupus. The board-certified rheumatologist noted this was typical in lupus patients and that stress often caused flares of lupus. The rheumatologist was of the opinion that Janet could not maintain full-time employment due to the stress of work and because her condition would result in absences on bad days.
The long-term disability insurance company had Janet’s file reviewed by an occupational medicine doctor. Occupational medicine doctors generally deal with workplace injury and illnesses caused by toxic and hazardous materials in a workplace.
Not surprisingly, the long-term disability insurance selected occupational medicine doctor disagreed with a board-certified rheumatologist on the nature and extent of Janet’s lupus as well as the noted symptoms and stressors related to Janet’s disease. The occupational medicine doctor believed Janet did not have any limitations that would prevent her from working.
The long-term disability insurance company followed the occupational medicine doctor’s opinion and denied benefits to Janet.
One of the arguments that Janet made on her appeal was that her board-certified rheumatologist was in a better position medically to comment and opine on her diagnosis and limitations given the specialty and the board certification.
The courts disagreed with Janet’s argument. The court stated all ERISA requires is reviewers have “appropriate training and experience in the field of medicine involved in the medical judgment” and an administrator does not abuse its discretion by selecting a reviewing physician who does not have the same specialty as the claimant’s treating physician.
Janet’s denial was upheld by the courts.
The takeaway is this: long-term disability insurance companies can use any medical reviewer of their choosing to deny your claim as long as the chosen doctor has appropriate training and experience in medicine.
This is such a wide definition that any doctor with a license will likely have the appropriate training and experience to comment on your condition and limitations. To prove this is not the case, you – the claimant – will be required to show that the reviewer does not have the appropriate training and experience!
This case illustrates why ERISA long-term disability claims are so difficult to prove and why having a skilled attorney who can craft a solid strategy for overturning a denial is so important!
The basic facts and law in the preceding story are taken from Davis v. Aetna Life Ins. Co., No. 16-10895 (5th Cir. 2017).