Why doesn't my treating physician's opinion matter in my disability case?

A:

We're taught from the very beginning to trust our doctors. The trust component of the physician-patient relationship is one of the most important aspects of choosing who you take medical advice from. After all, if you don't trust your doctor, how can you rely on his medical opinion?

So then why, when your doctor declares that you are "disabled" and can no longer work, is the insurance company allowed to ignore his opinion?

Because in 2003, the Supreme Court of the United States issued a ruling that long-term disability insurance companies do not have to give any deference to the opinions of the treating physician when evaluating a disability claim. When Kenneth Nord, a material planner with Black & Decker went to see his doctor about hip and back pain, he was told he might have a degenerative disc disease. After confirming the disease with an MRI, Kenneth was advised by his doctor to stop working at his "sedentary" job.

Following the advise of his doctor, Nord stopped working and applied for disability benefits. He was quickly denied and then filed his appeal. His doctors and Black & Decker's HR Department filed all the documents to support his claim. MetLife, who was the insurance company administering the claim, sent Nord to get a second opinion - from one of their doctors. While MetLife's doctors agreed that Nord had a degenerative disc disease, they also thought that if he took pain medication, he would be capable of sedentary work as long as he did "some walking interruption in between" work.

Even though Nord had the support of his physicians and Black & Decker's HR department, his appeal was denied. So he went to the courts.

The Court of Appeals reviewed Nord's case and decided that the insurance company had to justify its rejection of the treating physicians' opinion. Because MetLife had made no attempt to reject his opinion, the Court of Appeals declared that Nord should win.

But then the Supreme Court of the United States heard the case. After a full briefing and argument, the Court held that a disability plan did not have to give any special weight to the opinion of the treating physician. The Court reached this decision by reasoning that nothing in the ERISA law or the Department of Labor's regulations mandated that the insurance company give any special deference to the treating physician.

Even after the Supreme Court admitted that, "The validity of a claim to benefits under an ERISA plan is likely to turn on an interpretation of the terms of the plan at issue," the Court held in favor of MetLife. In short, whether you are "disabled" hinges more on what the terms of your plan are than on what the problems with your body are.