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The Problem with File Reviews in Disability Benefit Cases

The practice by insurance companies of hiring doctors to review disability benefit claim files has been coming under increasing fire.Doctors are hired to assess  a claimant's disability based on a review of records rather than examining the claimant or even speaking with the claimant or the treating doctors.A recent ruling from Tennessee, Carty v. Metro. Life Ins. Co., 2016 WL 7325334 (M.D. Tenn. December 15, 2016), joins a long list of cases that question the validity of file reviews, particularly in psychiatric cases or in cases requiring an assessment of symptom complaints such as pain or fatigue.The Carty case involved a claim for disability based on bipolar disorder, depression and anxiety.Another recent case questioning file reviews, Montero v. Bank of America Long-Term Disability Plan, 2016 WL 7444957 (W.D.N.C. December 27, 2016) , addressed file reviews in a case involving fibromyalgia, a condition in which symptoms of pain and fatigue can cause disability despite the absence of any neurologic or musculoskeletal findings.

Carty cited Sheehan v. Metropolitan Life Insurance. Co., 368 F.Supp.2d 228 (S.D.N.Y.2005), one of the first cases that pointed out the weakness inherent in a file review of a psychiatric case:

Courts discount the opinions of psychiatrists who have never seen the patient for obvious reasons. Unlike cardiologists or orthopedics, who can formulate medical opinions based upon objective findings derived from objective clinical tests, the psychiatrist typically treats his patient's subjective symptoms.... [W]hen a psychiatrist evaluates a patient's mental condition, "a lot of this depends on interviewing the patient and spending time with the patient,"...a methodology essential to understanding and treating the fears, anxieties, depression, and other subjective symptoms the patient describes.

The court concluded that the treating doctors were in a "superior position to directly evaluate Carty's symptoms, personality, and behaviors."In contrast, one of the insurance company's reviewing doctors offered a "laundry list of the symptoms Carty does not have," while the other focused solely on attention and concentration while disregarding Carty's other symptoms and his ability to cope with stressors.Thus the court overturned the benefit denial. 

In Montero, the court was troubled by the reviewing doctors' failure to rebut the diagnosis or complaints of disabling pain and fatigue, and concluded, in overturning the benefit denial, that 

the arguments made throughout this process have been like two ships passing in the night with Defendants focused on functional impairments and Plaintiff focused on disabling pain and fatigue. It was Defendants' burden to rebut Plaintiff's evidence, and by failing to do so, Defendant Aetna's decision to discontinue LTD benefits was not the result of a reasoned and principled decision-making process and was not supported by substantial evidence.

The point made by both of these cases is that insurance companies need to perform more examinations to decide disability benefit claims, especially if the claims involve a behavioral health condition or a condition where the primary symptoms are pain or fatigue.The willingness that courts have previously shown to accept the opinions of non-examining doctors has diminished as courts have become more distrustful of such findings.With more rulings such as Carty and Montero, that trend will continue.

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