The federal regulations which govern the process of benefit claims made pursuant to a benefits plan governed by the federal statute commonly referred to as “ERISA” has a specific process for review of benefit denials, looked over by the Medical Records Reviewer.
As discussed in other writings on this website, a claimant is required to exhaust administrative remedies prior to bringing a lawsuit to enforce the rights to denied benefits. On short term and long term disability benefit denials, once an administrative appeal of a benefit denial is submitted to the Plan Administrator (usually an insurance company), in addition to the time frames and other requirements governing that review, the Plan Administrator is required to have the claim reviewed by an outside physician, the Medical Records Reviewers.
This process rightly leaves a bitter taste in the mouths of claimants. Usually, the insurance policy provides a right in favor of the insurance company to have an Independent Medical Examination performed. However, most insurance companies eschew this right in favor of having the medical evidence reviewed by an outside physician, the “Medical Records Reviewer.”
While the federal regulations and the insurance companies try to suggest these hired guns are “independent,” nothing could be further from the truth. The doctors know who is paying them and who will likely send them more business if their opinions are favorable. Beyond that, it is clear these doctors have an insurance company slant. In fact, there is one entity out there known as the “University Disability Consortium” which is a group of university-level professors whose opinions are as predictable as the needs of the insurance company requires. They use a process known as “cherry picking” to work their way through the Medical Records Reviewer to determine that the claimant is not disabled or, in medical benefits claims, to determine that the prescribed treatment is not medically necessary. In fact, the insurance companies generally refer the claims to these doctors with prepared, leading questions they want to be answered thereby making even easier for the doctors to draft reports which could be generated without even any actual review of the medical records. These doctors are paid significant amounts of money for these opinions.
Unfortunately, the insurance companies are allowed to rely upon the opinions of these doctors over those of actual treating physicians. These Medical Records Reviewers have not had to trouble themselves with actual claimants who surely would not have voluntarily left a good paying job for the off chance they may be able to secure the disability benefits which insurance companies so routinely deny. In Social Security benefits claims, there is a “treating physician rule” which requires the Administrative Law Judge to give greater weight to the opinions of the treating physicians. Case Law pursuant to ERISA claims has determined that there is “treating physician rule.”
This unfortunate situation is just another part of the cruel trick which Congress played on the unsuspecting working class in the country when it passed ERISA. That statute gives the false and misleading belief that an employee has certain protections which are so watered down as to be almost non-existent. But, as long as the Courts continue to construe ERISA as they do, there is no way around. It is just another part of the difficulties faced in handling these claims; difficulties which warrant hiring an attorney to help you deal with these hidden pitfalls.
Please keep in mind that the foregoing is not intended as legal advice applicable to any individual person’s unique legal situation. Its sole purpose is to give a general idea of the existing status of the law as it applies to the point of law addressed above. You cannot rely on the foregoing as legal advice. You cannot make legal decisions based on its contents. If you have questions arising out of this point of law, you should contact an attorney who routinely handles claims involving policies of disability insurance. The law offices of Herbert M. Hill, P.A. handles such cases and would welcome the opportunity to discuss your case with you, at no charge. You can contact me at 407-839-0005 or at hmh@herbertmhill.com.
Herbert M. Hill, P.A. is a law firm located in Orlando, Florida with a practice extending throughout the state of Florida and the southeastern part of the United States, including Georgia and Alabama. Areas of practice include disability and employee benefit claims of all sorts. The firm handles any claims arising under the Employee Retirement Income Security Act (known and referred to as “ERISA”) for disability benefits, medical benefits, retirement benefits of any sort, including pension, 401k, termination agreements or the like as well as claims arising under private disability policies.
