IN SOCIAL SECURITY DISABILITY CASES AN ADMINISTRATIVE LAW JUDGE MAY NOT SUBSTITUTE HIS OR HER OWN JUDGMENT IN PLACE OF A MEDICAL EXPERT

In a Social Security Disability hearing, an Administrative Law Judge (“ALJ”) cannot replace a treating physician’s opinion with his or her own lay opinion. In other words, it is inappropriate for an ALJ to ignore or reject a medical opinion based only on his or her own medical understanding. That is, an ALJ cannot substitute his or her judgment for that of the medical and vocational experts.

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WHEN AN INSURANCE COMPANY TRIES TO REDEFINE A PHYSICAL ILLNESS AS A MENTAL ILLNESS TO LIMIT THE BENEFIT DURATION IT IS THE INSURANCE COMPANY THAT BEARS THE BURDEN OF PROOF

Sometimes insurance companies deny claims on grounds other than by arguing that their insured is not disabled. Indeed, it is not unusual for insurance companies to initially agree that an insured is disabled under the terms of the policy not only from her own occupation, but from any occupation, but then to claim that the benefits are limited to a relatively short period of time, like 24 months, due to a policy’s limitations on paying for disabilities caused by mental and nervous impairments.

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FEDERAL COURTS HAVE FOUND THAT STANDARD INSURANCE COMPANY ABUSES ITS DISCRETION IN ERISA LONG-TERM DISABILITY CASES BECAUSE OF ITS BIASED CLAIMS ADMINISTRATION

Standard Insurance Company has a history of biased claims administration as illustrated by recent federal court decisions.

In Oster v. Standard, 759 F.Supp.2d 1172 (N.D. California, Jan. 5, 2011), Standard abused its discretion, among other things, because “[It] did not comply with its obligation as an ERISA fiduciary to adhere to ‘higher-than-marketplace quality standards on insurers’ or ‘discharge [its] duties’ in respect to discretionary claims processing ‘solely in the interests’ of Oster, its claimant,” referencing Metropolitan Life Ins. Co. v. Glenn, 128 S.Ct. 2343, 2345 (2008), citing 29 U.S.C. 1104(a)(1), and instead, treated claimant “as an adversary during the claims process [casting] doubt on the credibility of its decision on appeal.”)

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WHY IT IS SO IMPORTANT THAT A SOCIAL SECURITY DISABILITY CLAIMANT’S TREATING PHYSICIANS SUPPORT HIS OR HER DISABILITY

With respect to the opinion of a Social Security disability Claimant’s treating physicians, according to 20 C.F.R. § 404.1527(d)(2), an Administrative Law Judge (“ALJ”) is supposed to give more weight to opinions from treating physicians since these sources are likely to be the medical professionals most familiar with a Claimant’s medical impairments. Additionally, an ALJ must consider the length of the treatment relationship and the frequency of examination, and the nature and extent of the treatment relationship. Continue reading “WHY IT IS SO IMPORTANT THAT A SOCIAL SECURITY DISABILITY CLAIMANT’S TREATING PHYSICIANS SUPPORT HIS OR HER DISABILITY”

INSURANCE COMPANIES IMPROPERLY RELY UPON OPINIONS OF NON-EXAMINING, FILE REVIEWING MEDICAL CONSULTANTS TO DENY BENEFITS IN ERISA LONG-TERM DISABILITY CASES

Under ERISA, before denying a claim, an insurance company or “plan” has “the responsibility to fully investigate” that claim. Capone v. Aetna Life Ins. Co., 592 F.3d 1189, 1199-1200 (11th Cir. 2010). Moreover, to survive judicial review, the termination of benefits must have “a reasoned explanation,” resulting from “a deliberate, principled reasoning process.” Davis v. Kentucky Fin. Cos. Ret. Plan, 887 F.2d 689, 693 (6th Cir. 1989); Killian v. Healthsource Provident Administrators, 152 F.3d 514, 520 (6th Cir. 1998). Continue reading “INSURANCE COMPANIES IMPROPERLY RELY UPON OPINIONS OF NON-EXAMINING, FILE REVIEWING MEDICAL CONSULTANTS TO DENY BENEFITS IN ERISA LONG-TERM DISABILITY CASES”

ERISA DISABILITY COVERAGE FOR IMPAIRMENTS CONSISTING PRIMARILY OF SELF-REPORTED SYMPTOMS

Some disability policies or ERISA plans limit coverage for “self-reported” symptoms. See, e.g., Chronister v. Baptist Health, 442 F.3d 648 (8th Cir. 2006) (2 year limitation for claims based on “self-reported” symptoms with “self-reported” defined as those that “are not verifiable using tests, procedures or clinical examinations standardly accepted in the practice of medicine”); Holcomb v. Unum Life Ins. Co. of Am., 578 F.3d 1187, 1188-89 (10th Cir. 2009) (similar limitation). Continue reading “ERISA DISABILITY COVERAGE FOR IMPAIRMENTS CONSISTING PRIMARILY OF SELF-REPORTED SYMPTOMS”

MIGRAINE HEADACHES AND DISABILITY

If you have chronic migraine headaches you may be a candidate for Long-Term Disability and Social Security Disability.

Migraine headaches can be incapacitating and disabling. “A migraine is defined as a condition that is marked by recurrent, usually unilateral severe headache often accompanied by nausea and vomiting and followed by sleep…that is uncertain in origin…” Cecil v. Reliance Standard Life Ins. Co.,7:05CV00003, 2005 WL 2291225 *5 (W.D. Va. Sept. 19, 2005).

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