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LTD insurer may not arbitrarily discredit treating doctors’ opinions

On Behalf of | Jun 4, 2021 | Insurance Company Tactics |

On March 22, 2021, the U.S. District Court in the Western District of Washington ordered Prudential to pay long-term disability (LTD) benefits to the claimant, a software engineer who said he was unable to work based on mental impairments that developed after abusive treatment at work. In Chapin v. Prudential Insurance Company of America, the judge found the opinions of Chapin’s treating doctors and therapist that the claimant was disabled from working as well as objective cognitive testing “compelling at the outset.”

The three treating professionals consistently diagnosed anxiety and depression that caused cognitive impairment. They had the opportunity to observe the claimant in person and assess his credibility.

To be disabled under the policy, claimant had to be unable to do regular work of a software engineer

For the first 24 months of payments under the long-term disability policy, the claimant had to be unable to perform his regular occupation. Chapin’s job was extremely high level from a performance standpoint, requiring technical experimentation, analysis, design, testing, aptitude and other advanced skills. He left his job to protect his mental and physical health at the recommendation of his doctor after bullying by a supervisor caused depression and insomnia from constant worry.

Cognitive testing showed deficits in psychomotor speed, delayed recall and difficulty with attention, all of which “would preclude plaintiff from performing the material and substantial duties of his regular occupation.”

Prudential’s peer review process

First, the insurer had a reviewing psychiatrist analyze the claimant’s medical file. This doctor said there was “no evidence” to support functional impairment, insufficient evidence of anxiety-caused impairment and “significant lack of objective data.”

Prudential then brought in a neuropsychologist to review the claimant’s medical evidence. Neither reviewing doctor examined the claimant. The second reviewer said that Dr. Olsen (the claimant’s main doctor) did not provide convincing evidence of mental impairments that would prevent “gainful activity” nor was there “measurable clinical evidence.”

This doctor suggested more advanced cognitive testing and wrote that Dr. Olsen’s opinion “cannot be considered independent” because he was a treating doctor. However, Prudential delayed ordering testing from neutral sources until it finally scheduled an Independent Medical Exam (IME) seven months after the second peer reviewer had suggested it.

Chapin filed the lawsuit instead of waiting for the IME appointment.

Too little, too late

The judge was not convinced by the quality of the reviewers’ analyses or Prudential’s investigation of the claim, finding:

  • Prudential breached its fiduciary duty to adequately investigate the claim and did not engage in the “meaningful dialogue” with the claimant that ERISA requires. It took the insurer seven months to request additional testing suggested by its own reviewer.
  • A “pure paper” review is a suspect basis for a denial of benefits.
  • The second reviewer showed an unfounded “presumption of bias” against the claimant’s main treating doctor.
  • Prudential said the record showed the claimant had “no mental illness” preventing him from being a “capable software engineer,” ignoring all the diagnoses of treating sources.
  • Rejecting treating doctor’s opinions arbitrarily, with no justification and without citing other credible evidence to the contrary is not justifiable and is improper.
  • Evidence that the claimant exercised and did volunteer work was not relevant to the question of whether he could perform the job of a software engineer.

While an insurance company may not automatically give the opinion of a treating medical professional special weight, the insurer must provide valid reasons for rejecting it and may not do so arbitrarily.

How can DI Law Group help? A delay or denial of disability claim can be financially devastating.  DI Law Group represents long term care and all disability insurance claimants at every stage of the insurance process.  If you have any questions regarding your life insurance claim, our team of attorneys would be happy to provide you with a free consultation.  Please contact us at 888-644-2644 or visit our website at www.dilawgroup.com.

(The Chapin case is available on Westlaw at 2021 WL 1090849.)

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