Court: Insurer Used 'Selective' Medical Evidence in Denying Disability Claim
>Summary judgment was granted in Ferguson v. Hartford Life and Accident Insurance Co. to the plaintiff by US District Judge Timothy Savage after finding that the insurer gave too little weight to the findings and opinions of the plaintiff’s treating physicians. “The treating physician rule requires that the opinions of a treating physician who is in a unique position to assess his patient’s health as a result of having treated him over time are entitled to substantial and at times controlling weight,” Savage wrote, according to a Legal Intelligencerreport.“Hartford was confronted with evaluating the opinions of numerous physicians, some of whom had treated Ferguson and others who had examined him or reviewed medical records at Hartford’s request. It chose to accept the opinions of the doctors it had hired and preferred over those of Ferguson’s doctors,” Savage wrote.
Dream Sequence
Ronald Ferguson began working at
Occidental Chemical Corp. in 1986 as a division manager. In
1992, he was promoted to human resources manager and
relocated from Texas to Pennsylvania.
Prior to transferring to Pennsylvania,
Ferguson was diagnosed with a sleep
disorder called central nervous system idiopathic
hypersomnia and prescribed treatment.
Following the transfer,
Ferguson continued treatment with a
different physician.
As the effectiveness of the stimulant
therapy decreased, Ferguson’s condition deteriorated, and
his physician prescribed several different stimulants to
combat Ferguson’s increased tolerance to his medication and
his worsening symptoms.
However,
in March 1996, Ferguson claims his sleep
disorder had worsened to the point that he felt he was
unable to perform his job duties. After consulting with his
physician, Ferguson resigned from his position at
Occidental and filed a disability claim with
Hartford.
Hartford denied the claim, advising Ferguson that he was “not totally disabled” as defined in the policy. Ferguson appealed and Hartford ordered Ferguson to undergo three medical examinations.
In the first, a doctor concluded that
there was insufficient reliable medical evidence to support
a diagnosis of idiopathic hypersomnia and that the cause of
Ferguson’s symptoms was his chronic dependence on
amphetamines and stimulants, and associated psychological
and emotional factors. Two neuropsychologists later
concluded that Ferguson had a lifelong learning disability
coupled with chronic fatigue that resulted in attention,
concentration and memory deficiencies. In the third exam, a
doctor concluded that it was unclear whether Ferguson
suffered from a sleep disorder, but said he could not rule
it out.
Hartford refused to reverse its initial decision to deny
coverage, finding the
reports of his treating physicians were
“not substantiated by the information we have reviewed.”
Ferguson filed suit in US District Court after Hartford
denied his appeal of the original decision.
Thoroughly Reviewed
Savage found that courts must apply a
deferential standard of review when considering the denial
of benefits under an ERISA plan. Ordinarily, Savage said,
application of that standard means that a court will not
reverse the administrator’s decision unless it was “without
reason, unsupported by substantial evidence or erroneous as
a matter of law.”
However,
courts employ a “heightened standard or
review,” Savage said, whenever “the evidence raises a
question of the plan administrator’s impartiality or there
is an inherent conflict of interest.”
Since Hartford both funded and
administered the plan, Savage found that a heightened
standard of review was mandated under the 2000 decision of
the US 3rd Circuit Court of Appeals in
Pinto v. Reliance Standard Life Insurance Co.
As a result, Savage said, “our inquiry focuses on whether
the insurance company was arbitrary and capricious in its
interpretation of the plan’s eligibility requirements and
its application of the facts presented.” Savage found that
Ferguson submitted two reports from doctors who had treated
him over five years.
Savage found that Hartford violated
the treating physician rule because it was “obvious” that
the insurer “did not give any weight, let alone
substantial or controlling weight, to Dr. Stafford’s or
Dr. Karacan’s [Ferguson’s physicians] findings and
conclusions.”
If the rule had been applied, Savage
said, Hartford “would have explained the basis for its
choosing its own doctors’ opinions and would have
addressed Dr. Stafford’s rebuttal to the reports of the
Hartford doctors.”