Insurance Company Tactics:
Ignoring Treating Physician Evidence

In most disability claims, insurance companies begin their investigation by requesting a report from your treating physician, along with medical records. However, if they are not happy with the treating physician’s opinion, they may turn to other tactics.

The case of Card v. Principal[1] is one example. In February 2013, registered licensed practical nurse Susan Card was diagnosed with chronic lymphocytic leukemia. Initially the condition was asymptomatic, but increasingly she began to experience worsening fatigue. She reduced her work hours and ultimately had to stop working altogether as her symptoms worsened. Card’s primary care physician noted her fatigue, easy exhaustion, chronic vaginal bleeding, feelings of depression and being wiped out, and night sweats, concluding that “she is failing work because of her disease and needs to go out on disability.” But in spite of all this, Principal denied her claim.

Due to increasing financial struggles, Card had to move states to live with her sister, having lost her house to foreclosure. Her primary care physician again informed the insurance company of Card’s inability to work and explained that, while her blood work looked better because she was no longer working, she was still dealing with chronic fatigue. He continued, “I do not see her being able to have any work capacity.” Her treating doctor then instructed her to follow up with new doctors upon her move. Card found a specialist in hematology and oncology and a gynecological oncologist, once she was able to find specialists that accepted medicaid. Card also appealed the initial denial but, again, Principal denied her claim in spite of her treating doctor’s statements that she was disabled.

In doing so, Principal essentially ignored Card’s doctor’s statements and justified their denial, in part, by claiming that Card had not submitted documentation that she was “under the regular and appropriate care of a physician” as required under the terms of her policy (Card’s policy, like most policies, contained a care provision, which establish additional requirements for qualifying for benefits).  However, in this instance,  Card’s physicians had told her that further appointments were not necessary in the months after her diagnosis (as is common in the early stages of chronic lymphocytic leukemia, given the nature of the disease).

Upon review, the Court found that none of the reviewers had adequately addressed Card’s specific health issue against the actual demands of her job (i.e. she could not be exposed to pathogens), nor addressed their reasoning for ignoring Card’s treating providers’ evidence and recommendations for the course/frequency of her treatment. The Court held that, while Principal was not required to give more weight to a claimant’s treating provider’s opinion, insurance companies cannot arbitrarily refuse to consider that opinion. The Court remanded the case, concluding that Principal’s decisions were not “the product of a principled and deliberative reasoning process.”

In this instance, Card  was fortunate to have had supportive physicians who documented her condition and why she could no longer work in her previous occupation. However,the Court ultimately had to step in to make sure Principal did what was right, demonstrating that sometimes supportive physicians and evidence may not be enough avoid a claim denial.

Every claim is unique and the discussion above is only a limited summary of the court’s ruling in this case. If your policy’s terms are not what you expected, an experienced disability insurance attorney can help you assess the situation and determine what options, if any, are available.

[1] Card v. Principal, No. 2019 WL 5618182 (U.S. Ct. of App. 6th Cir. Oct. 31, 2019)

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