Employers Need Not Apply 'Treating Physician Rule'

May 28, 2003 (PLANSPONSOR.com) - The United States Supreme Court unanimously held that employer-sponsored health care plans need not defer to an employee's doctor when deciding whether to cover disability claims.

With the ruling, the court rejected holdings by a  lower appellate court that found disability plans provided by private-sector companies under the Employee Retirement Income Security Act (ERISA) must apply a “treating physician rule” when evaluating employee claim. “We hold that plan administrators are not obliged to accord special deference to the opinions of treating physicians,” said Justice Ruth Bader Ginsburg in writing for the court.

The court found the“treating physician rule” imposed by the lower court was originally developed by Courts of Appeals as a means to control disability determinations by administrative law judges under the Social Security Act.   However, in 1991, the Commissioner of Social Security adopted regulations approving and formalizing use of the rule in the Social Security disability program.  Therefore, the high court found nothing in ERISA that suggests plan administrators must offer any special deference to the opinions of treating physicians, nor does ERISA impose any additional burden of explanation on administrators when they reject a treating physician’s opinion.

Ultimately, the court determined it should be left up to the state legislatures, not the courts, to decide if relying on the treating physician would help employer-funded plans make more accurate decisions about allegedly infirm workers.


The high court clarified the law on this issue, settling a dispute between Black & Decker Corp. and Kenneth Nord, an employee at the company. In the case, Nord, an employee for Black & Decker, filed for long-term disability for a back injury in 1997. The request was denied after the plan determined through an independent examination that Nord’s injury did not prevent him from doing his job.

That determination contradicted the view of Nord’s physician and Nord sued. A federal judge sided with the company, while a US 9thCircuit Court of Appeals panel reversed the lower court decision. The 9th Circuit ruling said the treating physician’s view takes precedence when there are conflicting opinions about an employee’s condition.

The case is Black & Decker Disability Plan v. Nord, 02-469.