The Importance of Treating Providers: A Case Study
We’ve talked before about how critical it can be to have a supportive treating provider on board when filing a disability insurance claim. This includes making sure your doctor knows what the definition of “disability” means under the terms of your policy, so that he or she can accurately opine on your ability to work in your specific profession.
Even if your doctor has provided a claim form (attending physician statement) in support of your claim, an insurance company or their reviewing doctors may still reach out in an attempt to get your treating physician to say you can work, or provide a firm return to work date that they can then use to deny or terminate your benefits.
One example of this is the case of Easter v. Hartford.[1] In this instance, the plaintiff, Audrey Easter, was a social worker who found herself needing to file a total disability claim with her insurer, Hartford. The underlying physically disabling conditions were chronic fatigue syndrome, obstructive sleep apnea, and hypersomnia. In support of her claim, Ms. Easter submitted an APS from both a Certified Physician’s Assistant (PA-C), Megan Jones, and an Advanced Practice Registered Nurse (APRN), Megan Sandy.
After reviewing the APS forms, Hartford sent a form letter to Easter’s APRN (Jones) asking for clarification on the level of activity Easter was able to perform. In response, Jones indicated that Easter was capable of performing sedentary and light activity. Hartford then arranged to speak by telephone to Jones, who stated that she was not aware that Ms. Easter had been out of work for as long as she had been and expressed that she would have thought Ms. Easter would have improved. Hartford subsequently denied Ms. Easter’s claim, alleging that her occupation was a sedentary one and that she was therefore able to perform the physical demands of her occupation.
Ms. Easter appealed Hartford’s decision. As part of its investigation during the appeal, Hartford referred the file to an outside vendor for an independent physician peer review. The reviewing physician, a Dr. Blavias, reached out to Ms. Easter’s providers again in peer-to-peer calls. Jones indicated that Ms. Easter’s symptoms appeared to be out of proportion to her degree of sleep apnea. While Sandy stood by her diagnosis of chronic fatigue syndrome, she also indicated that Ms. Easter’s sleep disorders and other medical issues did not seem adequate to explain the reported symptoms. Hartford upheld their denial on appeal and Ms. Easter subsequently filed a lawsuit.
In this instance, the Court sided with Hartford, indicating that Hartford had provided a detailed rationale for its decision and that their decision was supported by evidence—including the conversations that Dr. Blavias had with Ms. Easter’s treating providers, and Jones’s response on the form letter.
This case illustrates the importance of having a supportive physician who understands the nature of your disability, and how it affects your ability to work, on board when filing a disability insurance claim. If you have questions about how your insurance company is investigating your claim, 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] Easter v. Hartford Life & Accident Ins. Co., No. 21-4106, 2023 WL 3994383 (10th Cir. June 14, 2023)
