LTD Insurer Can Rely Upon Paper Reviewers Only

NJ Court finds that a plan administrator may rely on the opinions of doctors who have reviewed a patient’s medical records, but who have not physically examined the patient.

We often get asked whether long term disability insurers can rely upon the opinions of doctors’ who do a paper-only review in denying the insured’s LTD claim. A recent case out of New Jersey reinforces the reality that, at least in New Jersey, an LTD insurer may choose to credit the opinions of doctors who do a paper-only review, even if those opinions conflict with the views of the claimant’s treating physician.

Catherine was an employee at GlaxoSmithKline for over 11 years and participated in her employer’s Group Benefit Plan which was issued by Hartford. Beginning on July 29, 2008 Catherine began seeing several doctors with complaints of dizziness and nausea. After undergoing various tests Catherine was diagnosed with “dizziness, nausea, vomiting: complex partial seizures” and was prescribed valium to treat her symptoms.

As her symptoms worsened Catherine began having difficulty reading due to blurry vision and inability to focus and became unable to drive or tolerate motion. Ultimately, on May 11, 2009 Catherine’s conditions had progressed to the point forcing her to apply for long-term disability benefits with Hartford.

Hartford initially approved Catherine’s claim based on the opinions of her various treating physicians that Catherine was unable to drive or work. According to Catherine’s treating physicians she was:

“unable to work from home, as excessive visual stimulation worsens her symptomatology and ..reading, evaluating data, and computer work all worsen her symptoms.”

Hartford paid Catherine long-term disability benefits until January 14, 2010 when Hartford terminated Plaintiff’s benefits relying on responses from doctors hired by Hartford to conduct paper reviews of Catherine’s condition.

Catherine appealed Hartford’s denial to no avail–Hartford notified Catherine on November 22, 2010 that it would uphold its decision to terminate Catherine’s long-term disability benefits.

Catherine brought suit arguing that Hartford’s decision was arbitrary and capricious since, in addition to various other factors, Hartford had relied upon the opinions of doctors who reviewed Catherine’s medical records but did not physically examine her and that those doctors’ opinions conflicted with the opinion of Catherine’s treating physicians.

In finding for Hartford the court explained that the simple fact that Hartford accorded weight to the opinions of its reviewing physicians is not evidence that its termination decision was arbitrary and capricious. The court ultimately reinforced what many courts have held before–that an administrator may credit paper-only reviews, even though they conflict with treating physicians.