Insurance companies are notorious for relying on file reviews when reviewing disability claims and, unlike claims for social security disability benefits, insurance companies are often allowed to rely on file reviews even in spite of conflicting opinions by treating physicians who are arguably in a better position to assess the functional limitations of an individual. However, insurance companies cannot arbitrarily dismiss the opinions of credible treating physicians without providing an explanation and in certain circumstances courts have found that mere file reviews are insufficient to serve as a basis to deny a claim for benefits.
In a recent case decided by the Western District of Michigan, the Court found that psychiatric file reviews are insufficient to serve as a basis to deny a claim involving a mental health component. In Chamness vs. Liberty Life, James, Chamness, M.D., a pediatrician, became disabled due to depression and anxiety. He also alleged that he suffered from cardiac impairments and a sleep disorder, although these conditions did not serve as the primary focus of the court’s review.
In reviewing the case, the court found that the evidence supported Dr. Chamness’s claim and that liberty either ignored or overlooked the evidence in the claimant’s favor.
Relying on previous cases decided in the same circuit, the court concluded that the file reviews “are particularly questionable as a basis for an administrator’s determination to deny benefits where the claim involves a mental illness component.”
In other similar cases, courts had found that psychiatrists generally rely on self-reporting to diagnose and treat subjective complaints and file reviews by psychiatrists are viewed as particularly suspect since psychiatrists usually treat subjective, instead of objective, symptoms. The reason is that psychiatric impairments are not as readily amenable to substantiation by objective laboratory testing as are medical impairments and consequently, the diagnostic techniques in the field of psychiatry may be less tangible than those in the field of medicine. Therefore, accurately assessing the mental health of an individual generally requires 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 health component.
In this case, Dr. Chamness’s treating psychiatrist concluded that Dr. Chamness was unable to work as a doctor because his depression and anxiety affected his mental abilities to focus, concentrate, and remember. A consulting physician who also met with Dr. Chamness reached the same conclusion.
The psychiatrists on which Liberty Life relied did not meet with or examine Dr. Chamness. Additionally, the file reviewers insufficiently accounted for the evidence that Dr. Chamness’s depression and anxiety were affecting his mental faculties. Moreover, the court found those mental faculties are essential to being able to perform the essential duties of Dr. Chamness’s occupation.
It is important to note that in this case, there was evidence in the file to support the claimant’s claim for disability benefits based on a mental health condition. It did not appear there were any inconsistencies in the file or inconsistencies between the treating doctors’ opinions and the medical records. The file reviewing physicians, on which Liberty Life relied, also inadequately accounted for certain credible evidence in the file. For these reasons, the court relied on previous case law that a psychiatric file review was insufficient to deny this claim for disability benefits. Had the facts been different the court may have reached a different conclusion.
It is always important to understand that in certain circumstances, even in cases involving a mental health component, a court can find that a file review was an appropriate basis to deny a disability claim. Only a lawyer experienced in handling these types of claims can accurately assess the claim.