Courts face a challenging task when deciding disability benefit cases. That task is even harder with disability benefit cases brought under the ERISA law (Employee Retirement Income Security Act — 29 U.S.C. Sec. 1001, et seq.) where trials are rare.
However, a recent ruling from the U.S. District Court for the Southern District of New York in the case of Macalou v. First Unum Life Insurance Co., 2024 WL 4867091 (S.D. N.Y., Nov. 22), offers a commonsense guide to weighing medical opinions in such cases.
The case involved Anticia Macalou, a former employee of McKinsey, who brought an ERISA disability claim based on several behavioral health conditions. The court ruled in the plaintiff’s favor after finding the evidence she submitted from her treating and examining doctors was more persuasive than the opinions rendered by the defendant’s doctors, which were based solely on their review of the Macalou’s records.
The court acknowledged the Supreme Court’s directive in Black & Decker Disability Plan v. Nord, 538 U.S. 822, 834 (2003), finding that no special weight need be given to the opinions rendered by a disability claimant’s treating doctors. At the same time, though, Nord found that such opinions could not be arbitrarily discredited.
The 2nd U.S. Circuit Court of Appeals had previously pointed out in Connors v. Connecticut General Life Insurance Co., 272 F.3d 127, 135 (2d Cir. 2001), that in evaluating treating doctors’ opinions, courts should consider “the length and nature of the [physician-patient] relationship, the level of the doctor’s expertise, and the compatibility of the opinion with the other evidence.”
Another consideration, which was raised in Barbu v. Life Insurance Co. of North America, 35 F. Supp. 3d 274, 289 (E.D. N.Y. 2014), is whether a treating doctor’s opinion is based on doctor-patient relationships that commenced prior to litigation and evolved over time.
In contrast, opinions relied on by insurers in rejecting benefit claims may be given less weight due to their lack of firsthand knowledge of the claimant’s clinical condition. Giving greater weight to examining physicians is even more appropriate in claims that arise from psychiatric conditions.
A seminal case on that point was Sheehan v. Metropolitan Life Insurance Co., 368 F. Supp. 2d 228, 253 (S.D. N.Y. 2005), which the 2nd Circuit adopted in Winkler v. Metropolitan Life Insurance Co., 170 Fed.Appx. 167, 168 (2d Cir. 2006). Sheehan explained:
“Courts discount the opinions of psychiatrists who have never seen the patient for obvious reasons. Unlike cardiologists or orthopedists, who can formulate medical opinions based upon objective findings derived from objective clinical tests, the psychiatrist typically treats his patient’s subjective symptoms.”
Another important ruling on that point was Westphal v. Eastman Kodak Co., 05-cv-6120, 2006 WL 1720380, at *5 (W.D. N.Y., June 21, 2006), where the court pronounced, “There can be no serious doubt that a psychiatric opinion based on a face-to-face interview with the patient is more reliable than an opinion based on a review of a cold, medical record.”
Courts outside the 2nd Circuit have followed that rationale. See, e.g., Javery v. Lucent Technologies, Inc. Long Term Disability Plan for Mgmt. or LBA Emps., 741 F.3d 686, 702 (6th Cir. 2014); James v. Liberty Life Assurance Co. of Boston, 582 Fed. Appx. 581, 589 (6th Cir. 2014) (“Unlike most doctors … a psychiatrist must treat a patient’s subjective symptoms by interviewing the patient and spending time with the patient so as to understand and treat the subjective symptoms described by the patient”).
The Macalou court acknowledged that while nonexamining doctors with appropriate credentials and experience may, in appropriate situations, offer opinions that outweigh the findings made by treating doctors, the court found that the defendant’s reliance on nurses lacking demonstrable experience with psychological disabilities was insufficient. The court also found the treating and examining doctors’ opinions more credible because their opinions were consistent and “all corroborate one another with respect to Macalou’s diagnoses, the detrimental impact of these conditions on her functioning, and her inability to return to work.”
Those opinions were also reinforced by objective neuropsychological test findings. Thus, the court held the weight of the evidence was in the plaintiff’s favor.
While the 7th Circuit has not adopted Sheehan, in Hawkins v. First Union Corp. Long-Term Disability Plan, 326 F.3d 914, 916 (7th Cir. 2003), the court observed that a physician hired by disability insurers “may have a financial incentive to be hard-nosed in his claims evaluation in order to protect the financial integrity of the plan and of the employer who funds it.” Hence, “the superior information likely to be possessed by the creating physician” may outweigh the benefit plan’s consulting physician, especially where the plan has not obtained its own evaluation.
Since subjective symptom complaints comprise an important component of many disability benefit claims and are typically the main concern in claims based on behavioral health, the guidance offered by the court in Macalou is of great value both to the courts and to the parties. The checklist of points enumerated by the court on how to evaluate disability claims where the medical evidence is in conflict and the guidance on the weight to be given to the competing opinions will undoubtedly help decide future cases.
Mark DeBofsky is a shareholder at DeBofsky Law Ltd.
This article was first published by Chicago Daily Law Bulletin on December 17, 2024.
