In Pearson-Rhoads v. Aetna Life Insurance Company, the plaintiff sued for the payment of Long Term Disability insurance benefits from the insurer of her ERISA governed plan, Aetna Life Insurance Company. The plaintiff made numerous arguments. All were rejected by the court. Of particular note here is the plaintiff’s argument that Aetna abused its discretion by hiring its doctors to do “paper reviews” instead of deferring to the opinions of plaintiff’s treating doctors. The court rejects that argument like all of the plaintiff’s other arguments.
This is an example of how Courts are willing to reject the opinions of multiple treating physicians in favor of opinions by an insurance company doctor who did nothing more than a paper review of the claimant’s medical records.
[Note: this claim was not handled by the Ortiz Law Firm. It is merely summarized here for a better understanding of how Federal Courts are handling long term disability insurance claims.]
Aetna’s reliance on the opinions of its own consultants over the opinions of Plaintiff’s treating physicians does not render its denial of benefits arbitrary and capricious. Administrators of ERISA plans are not required to defer to the opinions of a participant’s treating physicians. Black & Decker Disability Plan v. Nord, 538 U.S. 822, 831 (2003); Orvosh v. Program of Group Ins. for Salaried Emps. of Volkswagen of Am., Inc., 222 F.3d 123, 127-31 (3d Cir. 2000) (administrator’s denial of benefits upheld despite the opinion of claimant’s treating physician that claimant was totally disabled). Seven of Aetna’s consultants reviewed all of the medical records submitted in support of Plaintiff’s claim, including those of her treating physicians. Many of Aetna’s consultants reviewed the entire file more than once and in one instance, three times. As reflected in their reports, Aetna’s consultants considered and addressed both the subjective complaints and physical examination findings observed by Plaintiff’s treating physicians, along with their diagnoses and impressions. Moreover, Aetna’s reliance on the opinions of highly qualified medical specialists demonstrates that its decision was reasonable.
That the conclusions of Aetna’s consultants were based on a paper review, rather than a physical examination, does not show that Aetna acted arbitrarily and capriciously. See, e.g., Dolfi v. Disability Reins. Mgmt. Servs., Inc., 584 F. Supp. 2d 709, 735 (M.D. Pa. 2008) (administrator’s paper-records review not arbitrary and capricious); Schlegel v. Life Ins. Co. of N. Am., 269 F. Supp. 2d 612, 627-28 (E.D. Pa. 2003) (administrator reasonably relied solely on a review of records by its own non-treating physicians). Because more than five months had passed between the motor vehicle accident that injured Plaintiff and her initial claim for benefits, the decision to forego an examination was reasonable. By the time Plaintiff initiated the appeal, more than a year had passed since the accident. There appeared to be little objective data to be gained by an examination. Aetna’s decision to forego an independent medical examination of Plaintiff was reasonable.
Here is a copy of the decision in PDF: Pearson-Rhoads v. Aetna