Long Term Disability: Treating Physician's Opinions

Social Security vs. ERISA Disability Claims

For social security disability claims, the treating physician's opinion is given special weight. Same is not true for an ERISA disability claim. Under ERISA, a treating physician’s opinion is to be considered but not to be afforded special weight. In The Black & Decker Disability Plan v. Kenneth L. Nord, 538 U.S. 822 (2003), the United States Supreme Court held:

"Plan administrators, of course, may not arbitrarily refuse to credit a claimant's reliable evidence, including the opinions of a treating physician. But, we hold, courts have no warrant to require administrators automatically to accord special weight to the opinions of a claimant's physician; nor may courts impose on plan administrators a discrete burden of explanation when they credit reliable evidence that conflicts with a treating physician’s evaluation."

In this case, the Plan defined "disability" as "the complete inability . . of a Participant to engage in his regular occupation with the Employer." The insurance company denied benefits. The employee had a sedentary job (material planner) requiring up to six hours of sitting and two hours of standing or walking per day. The employee was having hip and back pain. His doctor diagnosed mild degenerative disease which was confirmed by an MRI. The employee submitted doctors’ letters supporting his claim for disability. The employer completed a questionnaire which asked the employer to assume that the employee would have moderate pain that would interfere with his ability to perform interpersonal communications or act appropriately under stress up to one third to the day.

The employer asked if the under the assumed limitations, an individual could perform the work of a material planner and the employer answered no.

The Plan administrator sent the employee for an independent medical exam by a neurologist. The neurologist agreed that the employee had degenerative disc disease with chronic pain. The neurologist concluded that the employee could perform his job with some walking interruption in between and the employer offered this accommodation. The Plan Administrator continued to deny benefits and the employee appealed. The Federal District Court found that the denial of benefits by the Plan Administrator was not an abuse of discretion. The Ninth Circuit Court of Appeals reversed the District Court and granted summary judgment to the employee on the basis that the treating physicians opinions must be given more weight than an independent examination ordered by the Plan Administrator. The U. S. Supreme Court disagreed and reversed the Ninth Circuit ordering further proceedings. On remand, the Court held that the District Court's opinion was reinstated which held that the employee was not entitled to disability benefits under the Plan.