You know that claims administrators retain experts to review a claimant’s medical and mental health condition to assess whether a claimant is sufficiently impaired to be eligible for disability benefits.
But what happens when the claimant argues that a medical opinion should be rejected due to the sheer volume of opinions the expert has provided in other matters? And what discovery is allowed to examine that issue?
Here’s the recent case of Adkins v. Life Insurance Company of North America, __ F. Supp. 3d __ (E.D. WA., March 1, 2021)(attaching discovery Order denying discovery, and Order granting judgment in favor of Life Insurance Company of North America).
FACTS: Adkins, an office manager in a medical office, sought ERISA-governed disability benefits for cervical spine pain, and alleged cognitive deficiencies resulting from multiple automobile accidents. LINA granted benefits through her recovery from spinal surgery. But after LINA had two neurosurgeons and two mental health experts review the claim, LINA concluded Adkins could perform her sedentary job. Adkins appealed, and LINA had psychologist Dr. Elana Mendelssohn review the mental health records. She concluded Adkins was not cognitively disabled.
Adkins sued seeking benefits and a surcharge and injunctive relief under (a)(3). Adkins fiercely attacked the credibility of psychologist Dr. Mendelssohn, entering a series of unrelated cases into the record to assert Dr. Mendelssohn had a bias against claimants.
DISTRICT COURT HELD: DISCOVERY OF MEDICAL EXPERT DENIED; JUDGMENT IN FAVOR OF LINA ON BENEFIT CLAIM; FIDUCIARY CLAIM DISMISSED
ISSUE I: Discovery about Dr. Mendelssohn’s opinion history denied as being too expensive. Adkins sought information from LINA that would require LINA to review “every claim file during the relevant time at issue.” The Court found such discovery was “too expensive and burdensome” given that such information could be more easily obtained from Dr. Mendelssohn’s employer. Opinion on Reconsideration, at 3.
ISSUE 2: The Court rejected Plaintiff’s challenges to Dr. Mendelssohn’s credibility merely because she had reviewed many disability claims. “Plaintiff’s allegations of Dr. Mendelssohn’s bias are unpersuasive. Plaintiff points to the sheer volume of reviews Dr. Mendelssohn conducts for insurance companies to support her argument. However, the fact that Dr. Mendelssohn conducts a significant number of insurance claim reviews is insufficient on its own to demonstrate bias. … Plaintiff has not proffered any evidence to demonstrate Dr. Mendelssohn is biased against Plaintiff in particular or that Dr. Mendelssohn’s findings in favor of insurance companies are directly tied to a financial incentive (e.g., her pay is increased for favorable determinations or her pay is contingent solely upon favorable determinations).” Op. Granting LINA’s Motion for Judgment, at 24.
The Court distinguished other published cases involving other claimants, where courts were critical of Dr. Mendelssohn’s opinions regarding other claims. Op. at 24-26.
ISSUE 3. The Court gave a good list why experts’ reports submitted by claimant lacked credibility:
- Claimant’s 2018 psychologist report and opinion was contrary to the medical record. Op. at 20;
- Claimant’s treating physician’s opinions on impairment were not consistent with treatment notes, which showed claimant in better condition. Op. 20-1; and
- Claimant’s second psychologist mistakenly relied upon flawed assumptions found in the first expert’s report. Op. at 22.
ISSUE 4. ERISA “breach of fiduciary duty” claims fail if the underlying disability claim is affirmed. “As Plaintiff acknowledged during the telephonic hearing, her claim for breach of fiduciary duty is likely contingent upon the success of her claim for award of benefits under 29 U.S.C. § 1132(a)(1)(B). Having determined Plaintiff is not entitled to an award of benefits under § 1132(a)(1)(B), the Court finds additional discovery pertaining to her claim for breach of fiduciary duty is unnecessary as her claim under § 1132(a)(3) will likely fail. See, Wise v. MAXIMUS Fed. Servs., Inc., 478 F. Supp. 3d 873, 897 (N.D. Cal. 2020); Talbot v. Reliance Standard Life Ins. Co., No. CV-14-00231-PHX-DJH, 2018 WL 10419233, at *20 (D. Ariz. Feb. 7, 2018), aff’d, 790 F. App’x 129 (9th Cir. 2020); Mullin v. Scottsdale Healthcare Corp. Long Term Disability Plan, No. CV-15-01547-PHX-DLR, 2016 WL 107838, at *3 (D. Ariz. Jan. 11, 2016).” Order on Reconsideration, at 4.