The Wagner Law Group | Est. 1996

Sophisticated Legal Solutions And Boutique-Style Service

Insurer Need Not Defer to Participant’s Physician or Government Agency Decisions

On Behalf of | Dec 23, 2021 |

The Seventh Circuit Court of Appeals has ruled, in Feeney v. Unum Life Insurance, that an insurance company need not defer to either a participant’s treating physician or governmental agencies when determining if the participant is entitled to long term disability benefits.

Facts. The participant fell from a platform, sustaining a concussion and knee and back injuries. His own physician said that he had sustained a disabling injury. However, after a period of time, the insurer consulted with another physician who concluded that he had regained the physical capacity to return to work.

After the participant appealed this second opinion, the insurer then asked four new independent medical consultants to evaluate the participant’s medical records. They agreed that the participant was able to return to work.

The participant sued, claiming that the insurer had not given sufficient weight to his own physician’s evaluation. He also, asserted that the insurer had an obligation to supplement the record with two recent agency determinations extending disability benefits—one from the Department of Veterans Affairs and the other from the Social Security Administration. The lower court determined, based largely on the findings of the many doctors, that the participant did not have work‐precluding functional limitations, and that it was not arbitrary or capricious for the insurer to reach the decision denying further benefits.

Court of Appeals. On appeal, the Court ruled that the insurer did not “arbitrarily refuse to credit” the participant’s doctor’s opinion. At each stage of review, the insurer’s physicians sought her input and responded to her objections by soliciting opinions of independent consultants. The insurer reached its final decision only after determining that his physician’s opinions were inconsistent both with her own treatment notes and the findings of the other doctors. “Having adequately considered her opinion, the insurer was not required to defer to it.”

Similarly, the insurer was not obligated to defer to the government agencies’ rulings, which, the Court noted had, in any event, not been properly submitted for review.

Finally, the participant argued that the insurer improperly denied his appeal based solely on a “paper review,” without a current physical examination. The Court stated that there is no presumption under ERISA against a “paper review,” which enables doctors to evaluate medical information, to balance test results against the subjective opinions of treating physicians, and to provide an expert opinion without direct consultation.

Therefore, the court ruled in favor of the insurer and dismissed the case.