Treating Physicians Are Often Ignored in ERISA Litigation: Here's Why

Frequently, clients or prospective clients come to me baffled that their disability claim(s) have been denied. Their treating physician(s), after all, supported their claim, and even wrote a letter to the insurance company stating that the client was “permanently and totally disabled.” How, then, could the claim be denied?

In a very recent case out of Maryland, the court entered judgment against a disability claimant and, in the process noted that his treating physician’s letter to the effect that he was disabled was largely disregarded because, specifically, it failed to consider the definition of “disabled” contained in the policy. That may well be, according to the court, but I suspect that, at a more fundamental level, the insurer was permitted to disregard it for a broader, simpler reason: letters from doctors are not viewed as “clinical evidence” by any disability insurers and by very few courts.

This view, practically universal amongst ERISA insurers, is responsible for many claim denials but very little understanding. It is set forth in express plan language sometimes, but not always. Claim administrators, even those that strictly follow the rule, rarely bring attention to it. Claimants and physicians are completely blind to it.

Doctors practice in a environment in which they create medical reality for their patients and their support staff. Their diagnoses and decisions are rarely questioned by either. What they say goes. They are unaccustomed to situations in which their words or opinions are disregarded, but that’s exactly where they are in ERISA claims, where insurers are cloaked with virtually unlimited discretion, and authority, in the decision-making process. Unlike in the Social Security cases, where the law applies the vestiges of a formally-repealed-but-still-revered “treating physician rule” (vesting substantial authority in the opinions of treating physicians), ERISA claims administrators are free to ignore what doctors say. And so are the courts.

What carries the day in ERISA claims is “clinical evidence”. Diagnostic material such as lab work, imaging (x-rays, MRI’s, CT scans, etc.), other types of medically-recognized testing, observable symptomology and office notes are clinical evidence. They carry the day in ERISA disability claims. Letters from doctors don’t.

So, during the administrative appeal process, focus on compiling true clinical evidence to support the claim, from as many treating physicians as possible, and get it into the hands of the claims administrator. Letters from those individuals may get you out of gym class, but they won’t get you disability status.