People often contact us asking how they can be approved for Social Security Disability benefits yet be denied by their insurance company. Another recurring question is how the insurer can rely on the opinion of a physician hired to perform a file review over the opinion of a treating physician. While insurance companies are allowed to make a decision that is different from the SSA and/or rely on their own file reviews in many cases, they cannot do so arbitrarily. In other words, they have to provide a reason why they rely on such information over other, perhaps more credible information.
A recent case decided by a district court out of Michigan addresses these questions and involves Liberty Life Assurance Company of Boston. There is nothing groundbreaking about this court ruling but the court decision provides a good review of prior rulings in which other courts have assessed the value to be placed on SSA findings and the weight to be given to a reviewing doctor and vocational reports based solely on a reviewing doctors opinion.
In this case, the claimant had a long history of treatment for her lower back and thoracic spine dating back to at least 2006. Over the years she was able to manage the pain and continue working with treatment but as time went on her pain became less responsive to conservative treatment. Eventually, conservative treatment proved to be insufficient to control the pain.
Despite her doctors best efforts she had to stop working by June 2012 to undergo a lumbar fusion and was unable to return to work following the surgery because the pain was so severe. When she filed her claim, liberty requested that she complete activities questionnaires, which reflected her declining condition. She reported that she could not perform gainful employment due to pain in her back; leg pain; difficulty in sitting, standing and walking for any length of time. She also reported that she spent 14 hours a day in bed.
Concurrent with her application with liberty, she applied for SSDI benefits which were approved. Liberty also approved her claim and paid her benefits during the own occupation period but denied her benefits after the first 24-months of payments following a file review that determined she could work at a light-exertion level occupation.
Based on that file review, a vocational consultant found her capable of working at other occupations and her benefits were terminated in sept 2014.
She appealed, submitting a report from her primary care physician stating she could not work on a full time basis at any occupation due to her uncontrolled pain.
Liberty rejected this opinion and upheld its decision which led to litigation.
The court applied a de novo standard of judicial review and after reviewing the claim, the court found for the claimant. In addition to the treatment records the court gave great weight to the SSA finding based on a 2008 6th circuit court case which found that if: A plan administrator encourages an applicant to apply for SSDI benefits, financially benefits from the applicant’s receipt of SSDI benefits and then fails to explain why it is taking a position different from the SSA on the finding of disability, the reviewing court should weigh this in favor of a finding that the decision was arbitrary and capricious.
Since those factors were met and there was an absence of an explanation as to why Liberty accorded more weight to its reviewing doctor than to the treating doctor, the court placed heavy emphasis on the SSA determination.
The court also recognized the treatment records, which evidenced a clear pattern of pain and lack of improvement and found the treating physicians’ opinions were consistent with the medical evidence.
In regards to the reviewing doctor’s opinion, the court assigned less weight for several reasons: first, the reviewing doctor did not perform an in person examination of the claimant; also, the record showed that the doctor did not have all the available evidence when performing his review including pertinent records from 2011. Liberty also failed to provide the doctor with the SSA’s finding of disability.
Ultimately, this case is a good example of an inadequate review on the part of Liberty Mutual. It is important to remember that not every case will hinge on a Social Security decision and a Social Security finding of disability is not always weighed so heavily. The weight afforded to the SSA decision in this case had a lot to do with the inadequacy of Liberty’s review and the also the credibility of the claimant’s medical history.