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Treating Physician

Treating Physician's Opinion May Be Discounted When Inconsistent or Contradicted by Specialists

ERISA and Life Insurance News
(February 6, 2012)

Scott’s claim for disability benefits under an ERISA plan sponsored by her employer was approved in 1998.

In 2004, after Scott had surgery to address the medical issue that formed the original basis of her claim, Eaton terminated the payment of disability benefits for "insufficient documentation of a functional impairment that would preclude her from the job duties of any occupation."

Scott appealed the termination, and Eaton reinstated the benefits after an independent medical evaluation revealed a possible other basis for disability secondary to the surgery.

Over the next several years, during periodic reviews of Scott’s eligibility for continued benefits, she was diagnosed with different potentially disabling conditions – each of which involved conflicting evidence. Doctors disagreed as to diagnoses of reflex sympathetic dystrophy and mental illness.

After submitting the conflicting information to an independent physician reviewer, Eaton concluded that Scott could perform sedentary work, and the payment of benefits was terminated in 2008.

During the administrative appeal process, which involved two stages, six different physicians reviewed the claim. They each concluded that Scott could work, and the termination of disability benefits was upheld.

Scott then filed suit in federal court seeking reinstatement of benefits. The district court reversed Eaton’s decision to terminate benefits, finding that the company abused its discretion by giving inadequate weight to Scott’s treating physician, and by failing to adequately consider the impact of Scott’s medication regimen on her ability to work.

Eaton appealed, and the Fourth Circuit reversed, emphasizing the deferential nature of the abuse of discretion standard of review and holding that Eaton’s decision-making process was sound and its ultimate decision was supported by substantial evidence.

The appellate court concluded that Eaton adequately considered the opinions of Scott’s treating physician, but gave them little weight because of their inconsistency and because many of the opinions were not based on objective evidence.

Moreover, the opinions of the treating physician – characterized by the appellate court as "a well-meaning family doctor" – were contradicted by several specialists.

The appellate court also ruled that the district court incorrectly concluded that Eaton had ignored Scott’s medication in concluding that she was able work.

Click Here to view the full February 2012 Edition of the ERISA and Life Insurance News.

H. Sanders Carter
T (404) 962-1015
F (404) 962-1220
Kenton J. Coppage
T (404) 962-1065
F (404) 962-1256
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