An ERISA Insurer Cannot Refuse To Credit The Claimant’s Medical Evidence Without A Sufficient Explanation

In the recent case of Backman v. Unum Life Ins. Co. of Am., 2016 U.S. Dist. LEXIS 74918 (N.D. Cal. June 8, 2016), in which the claimant sought disability benefits for a painful back injury, the US District Court for the Northern District reversed Unum’s denial and ordered the payment of benefits. Unum had denied benefits based on the opinions of its own hired medical consultants. However, Unum’s consultants dismissed the well reasoned opinions of the claimant’s long time treating physicians without explaining why their opinions were not correct.

In deciding the case, the District Court stressed that it improper for an ERISA insurer to accept the opinions of its handpicked experts over the treating physicians where those experts never explain in any reasoned way why the treating physician’s opinions are incorrect As the Backman Court stated at pages 48-49:

“The Ninth Circuit has cautioned that “complete disregard for a contrary conclusion without so much as an explanation raises questions about whether an adverse benefits determination was ‘the product of a principled and deliberative reasoning process.’ Salomaa, 642 F.3d at 679 n. 35; see also Montour v. Hartford Life & Acc. Ins. Co., 588 F.3d 623, 635 (9th Cir. 2009). Here, Unum maintained its opinion that Backman’s pain was out of proportion to the clinical and diagnostic findings in the record, despite contrary conclusions from her treating physicians, with little credible explanation for why it dismissed those conclusions…”

Other District Courts have strongly criticized the ERISA insurer for seizing upon the opinions of its hired consultants who say that the claimant is not disabled where those consultants dismiss without a reasoned explanation the opinions of the treating physicians. See, for example, James v. AT&T West Disability Benefits Program, 41 F. Supp. 3d 849, 879, (N.D. Cal. 2014).

If you were denied disability benefits insurer never explains in any reasoned, sensible way why the opinions of your treating physicians are not valid, it is likely that your insurer has violated the settled rules and standards in the federal courts that apply to your case.

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An ERISA Insurer Cannot Refuse To Credit The Claimant’s Medical Evidence Without A Sufficient Explanation

appeared first on San Francisco Top Disability Attorney and Insurance Claim Denial Law Firm.


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