Reliance Standard Medical Reviewers May Face Conflict of Interest

In this blog we often comment about medical doctors who derive most if not all of their income testifying for insurance companies and health plans. As a result, it’s never a surprise when their review of a policyholder’s medical file reaches a conclusion in favor of the insurance carrier.

“How a Medical Reviewer Helped Reliance Standard Deny Disability Claims,” The Insurance Forum (June 2010), highlights William S. Hauptman, a Philadelphia gastroenterologist who worked as a medical reviewer for Reliance Standard Life Insurance Company on disability claims. Dr. Hauptman’s support of adverse claims decisions was mentioned in several lawsuits filed against Reliance, including a case our firm successfully appealed, Gunn v. Reliance, No. 04-01852 (U.S. District Court, Central District of California).

Igor Gunn, a UBS/PaineWebber financial advisor, was diagnosed with symptoms of multiple sclerosis, including fainting spells, constant dizziness, fatigue, balance problems, cognitive difficulty and depression. His long-term disability plan administered by Reliance paid Mr. Gunn benefits for two years while the plan investigated his claim. Mr. Gunn submitted medical evaluations from his psychiatrist and three physicians. Two concluded Mr. Gunn was totally disabled; the other two submitted treatment notes. Mr. Gunn’s psychologist concluded he was completely disabled on “both medical and psychological grounds.”

Mr. Gunn’s plan would pay benefits for physical conditions, but not for mental or nervous disorders after two years unless Mr. Gunn was in a hospital or institution. This policy language becomes important because of what happened next.

Although five of Mr. Gunn’s physicians were clearly treating him for physical as well as psychological symptoms, the physician from whom Reliance sought an independent evaluation, Dr. Carl Orfuss, concluded that 99 percent of Mr. Gunn’s disability stemmed from “psychiatric problems.” As a result, Reliance informed Mr. Gunn that he was not physically impaired, benefits would terminate and he must return to work. Mr. Gunn appealed he decision, including in his appeal a doctor’s diagnosis of physical disability from multiple sclerosis.

Reliance asked Dr. Hauptman to review the medical file, and he agreed with Dr. Orfuss that “consistent with the entirety of the medical records” 99 percent of Mr. Gunn’s disability resulted from depression. Reliance denied the appeal and Mr. Gunn sued in federal court.

The District Court, ruling that Mr. Gunn was entitled to benefits, had a very decided opinion about Dr. Hauptman: “Reliance is the only insurance company for which Dr. Hauptman works, and he derived approximately one-third of his income from his work with Reliance. Reliance prohibits Dr. Hauptman from contacting a beneficiary’s treating physicians to discuss those physician’s opinions unless he first receives permission from Reliance.”

Joseph M. Belth,editor of The Insurance Forum, sums up the situation in the June 2010 issue of his newsletter this way:

“I believe that Reliance and other disability insurers use many physicians to help the companies deny claims. Using a physician in that way creates a serious conflict of interest for the physician. The physician knows that the company wants his or her support for adverse claims decisions, that he or she will be paid generously for providing that support, and that failing to provide that support will discourage the company from using the physician.

Ideally, disability insurers should be looking for ways to honor claims rather than looking for ways to deny claims. In the absence of that ideal situation, it is difficult to address the above conflict of interest. One possibility would be to disclose publicly the number and percentage of cases handled by a physician where he or she recommended denial of a claim.”

We find it highly unlikely that insurance carriers will choose to address this conflict of interest the way Mr. Belth suggests because that would make it too easy for courts to throw out biased testimony. Rather, they will continue to look for ways to deny claims and make you fight to prove their examining physician has a serious conflict of interest.

If your claim has been denied because your health plan relied on the report of their hired doctor who made an analysis that contradicts your own physician’s diagnosis, please contact us at (800) 446-7529 and let us help you fight for the benefits you deserve.

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