A "file review" by a medical professional labeled "independent" by the insurance company is often a part of disability insurance claims process. The Sixth Circuit recently considered the strengths and weaknesses of such a "file review" in Okuno v. Reliance Standard Ins. Co. This opinion yielded a number of interesting points to consider:
- While there is "nothing inherently improper with relying on a file review," we have observed that "the failure to conduct a physical examination, where the Plan document gave the plan administrator the right to do so," as Reliance's Plan expressly does, "raises questions about the thoroughness and accuracy of the benefits determination."
- File reviews are particularly "questionable as a basis" for an administrator's determination to deny benefits where the claim, as here, involves a mental illness component. Evaluation of mental health necessarily involves "subjective symptoms," which are most accurately ascertained through "interviewing the patient and spending time with the patient," such that a purely record review will often be inadequate where a disability claim includes a mental component.
- Another deficiency in Reliance Standard's file review is its "failure to consult with medical professionals with relevant expertise. See 29 CFR § 2560.503-1(h)(3)(iii)(requiring plan administrators, "in deciding an appeal of an adverse benefit determination that is based in whole or in part on a medical judgment" to "consult with a health care professional who has appropriate training and experience in the field of medicine involved in the medical judgment.").
- While ERISA does not demand an examination by the narrowest of specialists, we have noted its requirement that administrators retain health care professionals in the specific field of medicine at issue. ... Reliance's failure to consult with a mental health expert -- particularly when it denied Okuno benefits on the basis that her disability included a psychiatric component -- indicates a lack of deliberate and reasoned decision-making.
- The record contains no indication that Reliance's reviewing health care professionals ever consulted with Okuno's treating physicians, the only doctors to actually examine her. ... While Reliance was not required to accord special deference to the opinions of Okuno's own doctors, "by the same token, it may not arbitrarily repudiate or refuse to consider the opinions of a treating physician."
In sum, a file review is not per se inadequate but its use raises questions where the claim has a psychiatric component. The disability insurance company should use medical consultants with expertise in the relevant medical field. Finally, there should be some communication with the claimant's treating physicians and there should be some reasoned discussion of their opinions.
For further reading: Has Your Claim for Disability Insurance Benefits Been Denied Based on a Preexisting Condition? and Has Reliance Standard Denied Your Disability Insurance Benefits Claim Based on a Mental Disorder or Condition?
Robert L. Abell
www.RobertAbellLaw.com
