Treating Physician Rule Change & Who to Believe
The treating physician rule required decision-makers to accord special deference to the opinions of treating physicians. The rule is no longer applicable in Social Security cases or ERISA cases. In 2003, the Supreme Court adopted what is considered to be a middle-of-the-road approach, in which decision-makers were not to accord special weight to the opinions of treating physicians, but at the same time, they could not “arbitrarily refuse to credit” a claimant's reliable evidence from treating physicians. Black & Decker Disability Plan v. Nord, 538 U.S. 822 (2003). So, who is a judge to believe?
In the Stratton v. Life Ins. Co. of North Am., No. 20-CV-2037 JLS (NLS), 2022 WL 712926 (S.D. Cal. Mar. 8, 2022), Judge Janis L. Sammartino addressed this issue in an ERISA case.
Facts of the Case:
Stratton was a senior executive who suffered from significant back pain beginning in 2011. She struggled with it for about six years, calling in sick for meetings, avoiding lengthy plane travel, and sitting for an extended period.
In 2017, she filed a disability claim under the insurance policy in place for employees.
The Life Insurance Company of North America (LINA) denied the claim.
Stratton hired an attorney and submitted a functional capacity evaluation and the opinion of a treating physician.
LINA reversed course and paid the claim.
Stratton filed a claim for the waiver of premium life insurance benefit when it became clear the back pain was there to stay. This benefit is a means of keeping significant life insurance in place when one may not otherwise be insurable or only insurable at great expense. She thought LINA would easily find she was disabled given that it had found her disabled and thus eligible for long-term disability benefits.
LINA denied her waiver of premium claim and then terminated her long-term disability benefits.
LINA hired doctors who provided opinions to support its decision and:
Noted a lack of objective medical evidence of her disability in the record, largely due to Stratton’s restrictions being based on pain. Since pain cannot be measured by a diagnostic test or tool, some doctors simply disregard it.
Noted that Stratton did not have back surgery. Her surgeon did recommend back surgery because it was not likely to resolve the pain but could make it worse.
Misread or ignored Stratton’s functional capacity evaluations.
LINA denied the claims.
Stratton exhausted all appeals and then filed a lawsuit claiming both benefits.
In determining which doctors to believe, the court evaluated the credibility of their opinions. The court found:
The treating doctor’s opinion was consistent with two functional capacity evaluations and with the claim record.
MRIs and x-rays revealed conditions that were consistent with Stratton’s complaints of pain, further supporting her treating physician’s opinion.
The opinion of one of LINA’s physicians agreed with Stratton’s treating doctor’s opinion.
The court noted some credibility issues with LINA's physicians:
They required objective evidence, but the plan document did not.
There were mistakes in their reviews, such as the misreading of Stratton’s diagnosis and FCEs.
They never examined Stratton. Their opinions were based entirely on the medical records, from which it is extremely difficult or impossible to evaluate pain.
They said Stratton was capable of sedentary employment because she could drive, use a computer, walk, and do other household and personal tasks. However, these tasks do not demonstrate the ability to perform a sedentary occupation.
They based their opinion in part on Stratton not having back surgery.
This decision provides some evenhanded and fair guidance from a court. When it comes to pain, it is necessary to evaluate the credibility of the complaints. Where there are conditions that are demonstrated on MRIs and x-rays that are known by treating physicians to cause pain in patients, the credibility of the complaints is strengthened. When an individual is not able to perform a well-compensated occupation and instead receives only a fraction of pre-disability income (most policies only provide 50% or 60% of earnings), they are also reinforced.