Relying on File Reviews: A Case Study
It is not uncommon for disability insurance companies to rely on paper-only reviews when deciding whether to deny or terminate benefits. But will the reviewing physician consider all the evidence submitted in support of a claim when making a determination on whether an insured is disabled? The answer is – not always.
One such example is the case of Caudill v. Hartford.[1] Caudill filed a claim with his insurance company, Hartford, based on fibromyalgia and chronic obstructive pulmonary disorder (CODP). Hartford initially began paying benefits but later terminated them, claiming that Caudill was no longer too disabled to work. Caudill appealed, but Hartford upheld its termination. When making this decision, Hartford relied almost solely on an independent file review conducted by a Dr. Schulman.
Dr. Schulman opined that Caudill was able to work because he could sit or stand for 8 hours a day. While his conclusion concurred with the view of a doctor who had previously conduced an independent medical examination (IME), it failed to address questions that had been raised by Caudill about the purported deficiencies in the IME. Further, Dr. Schulman did not address a functional capacity evaluation (FCE) that reached a conclusion that Caudill’s issues, even with sitting, “would not be viable in most sedentary environments.”
Neither Dr. Schulman or the Hartford addressed the notes of Caudill’s treating physicians, which included statements that Caudill “does not have good exertional tolerance” and that he has difficulties with activities of daily living.
While the Court explained that, while there was nothing inherently objectionable about a file review, in this instance Caudill had “provided credible, objective evidence that he is unable to work in even a sedentary capacity” and that Hartford “cannot arbitrarily disregard a claimant’s evidence.” The Court found for Caudill and ordered that his benefits be retroactively reinstated.
This case highlights how insurance companies may rely on their own experts over other evidence in the case file. If you believe your insurance company has conducted a file review and you have questions, please feel free to reach out to one of our attorneys directly.
Every claim is unique and the discussion above is only a limited summary of the court’s ruling in this case. If you are concerned that your insurer is not evaluating your claim under the proper standard, an experienced disability insurance attorney can help you assess the situation and determine what options, if any, are available.
[1] Caudill v. Hartford Life & Accident Ins. Co., No. 1:19-CV-963, 2023 WL 2306666 (S.D. Ohio Mar. 1, 2023)
