A Disability Benefits Ruling Highlights Importance of Knowing Your Case Facts

A consulting physician’s opinions don’t count as substantial evidence. That’s the ruling in the recently released United States Fifth Circuit Court of Appeal case of Lauren Bray v. Fort Dearborn Life Insurance Company (No. 07-11001, filed March 9, 2009).

The Fifth Circuit upheld the District Court’s opinion that Fort Dearborn’s decision to stop Bray’s “own occupation” long-term disability benefits was an abuse of discretion in this ERISA benefits case.

In finding this, the Fifth Circuit stated, “the opinions of [Fort Dearborn’s] consulting physicians are not substantial evidence supporting the denial of benefits because they were based only on a surveillance video depicting activity not comparable to Bray’s work duties and an alleged lack of objective medical evidence supporting her complaints of pain.”

The Court noted that Bray’s own doctors did provide evidence establishing the existence of an objective condition that could cause the pain.

The Court also acknowledged that because the administrator had a conflict of interest, its decision was entitled to less deference than usual.

While this case was tagged as not for publication by the Court, it does give insight into how the facts in each case are reviewed by the Courts and what you must do to give yourself the best chance of receiving the benefits you deserve.

For example, this case highlights the lengths long-term disability benefits providers will go to not pay your benefits. Fort Dearborn had Ms. Bray videotaped even though she was already on benefits.

Fort Dearborn also based its decision to terminate benefits on the opinion of a doctor who never spoke to Bray but only reviewed a video. Give them an inch, and they’ll take a mile.

This opinion also highlights the importance of getting your doctor on board and knowing your medical records.