If you're interested in the full opinion of Blankenship v. MetLife, be prepared for an astute critique of the problems and shortcomings of ERISA.
Judge William Acker, Jr. of the USDC Northern District of Alabama continued his assault on the judicial application of ERISA recently with his opinion on Blankenship v. Metlife.
Disability Claim Denied for Man with Heart Condition and Knee Problems
Blankenship was a manager at a large Sears Roebuck department store in Alabama who had a significant cardiac history and suffered from advanced heart disease. His treating physicians determined that he was unable to continue working in the stressful environment of his job and he filed for disability. After several reversals on MetLife's part, benefits were denied.
A short time later Blankenship underwent knee surgery and was granted benefits based on that condition. MetLife continued to review the claim and had a vocational specialist review Blankenship's job capabilities. The specialist ignored his heart problem and focused solely on jobs that were open to someone with knee problems. The specialist found several jobs, all of which would have been precluded by his heart condition, and his claim was again denied.
Blankenship appealed again and MetLife had a cardiologist review the file. The cardiologist never addressed the main concern of Blankenship's treating physicians, that the stress of work would cause him further cardiac episodes. Based on the report, MetLife denied the appeal.
The Insurance Company's Doctors Almost Never Look Past Your Case File
In his opinion, Judge Acker is critical of ERISA on several points. First, he cites the problem with ERISA cases being based solely on paper and the fact that the courts purport to make "credibility determinations to resolve disputes between irreconcilable unsworn written testimony."Along with this, the judge questions the weight given to experts for the insurance companies. These experts often present their opinions following a simple file review and without ever having examined the claimant. The opinions of these doctors is then pitted equally against that of the treating physicians.
Insurance Company's Doctors Are Paid to Deny, Deny, Deny
Second, Acker discusses the inherent conflict of interest that faces the insurers in ERISA cases. The insurers who determine whether or not benefits should be awarded are also the ones that pay out the benefits. The possibility of this conflict and the apparent actions of insurers is certainly enough to suspect that it is indeed an active conflict. Employees make decisions whether or not to give out their employer's money. This conflict also extends to the doctors hired to review the files as many are non-practicing and make their living solely on insurance file reviews. A conflict exists because a doctor who is unwilling to "deny, deny, deny" will lose the insurance company's business and suffer financial loss.
Lastly, the judge harps on the perversion of ERISA, the Employee Retirement Income Security Act, a law meant to protect the benefits of American employees by giving them access to the courts following insurance denial. Unfortunately, the courts have defied the spirit of the law and it is now used as a bastion for insurance companies rather than a reprieve for the insured.