High Court Nixes "Treating Physician Rule"

The court said that the employer was within its rights when it instead accepted the assessment of an independent neurologist that the employee, if aided by pain medication, could do sedentary work.

The Washington-based National Association of Manufacturers said the case?Black & Decker v. Nord, was important for preserving final authority on worker disability claims for the lawful administrators of employer-sponsored plans.

Quentin Riegel, vice president for litigation with NAM, said the plaintiffs in the case wanted treating physicians to have discretionary authority in determining eligibility for benefits.

Plan administrators, he said, would have been left with the sizable burden of collecting "substantial evidence" to rebut the decisions of treating physicians.

This, Mr. Riegel said, would have created administrative nightmares for employers, while the additional costs of gathering rebuttal evidence and litigating physician's disability decisions would have further eroded employer health and disability plans.

In the case, a Black & Decker employee named Kenneth L. Nord was diagnosed with a degenerative disc disorder. Mr. Nord was placed on pain medication for one week, but his condition did not improve.

His treating physician recommended that Mr. Nord cease working temporarily and consult an orthopedic specialist.

Mr. Nord filed a claim for disability benefits. But MetLife, which had been delegated authority from Black & Decker to assess benefit claims, issued an initial recommendation that it be rejected.

Mr. Nord then followed an appeals procedure in which he submitted letters from his treating physician and the orthopedist supporting his claim.

MetLife referred Mr. Nord to a neurologist for an independent examination. The neurologist agreed that Mr. Nord suffered from a degenerative disorder and had chronic pain. However, the neurologist said that with the aid of pain medication, Mr. Nord could perform sedentary work.

MetLife issued a final recommendation to reject the claim, which Black & Decker did.

Mr. Nord filed a federal lawsuit seeking to overturn the rejection. A United States District Court ruled in favor of Black & Decker, saying that the company's rejection of the claim was not an abuse of discretion.

However, the Ninth Circuit Court of Appeals reversed, arguing that plan administrators must follow a "treating physician rule." According to the Ninth Circuit, the rule requires administrators who reject the opinions of treating physicians to come forward with specific reasons based on "substantial evidence."

The Ninth Circuit ruled that Black & Decker had not provided adequate justification for rejecting the treating physician's opinion.

Black & Decker appealed the United States Supreme Court, which ruled unanimously that the "treating physician rule" does not apply to employee benefit claims made under the Employee Retirement Income Security Act.

In an opinion written by Justice Ruth Bader Ginsburg, the court said that the "treating physician rule" cited by the Ninth Circuit originated as a means to control disability determinations by administrative law judges under the Social Security Act.

However, the Supreme Court said, the Ninth Circuit erred in applying this rule to ERISA determinations.

Nothing in ERISA, the court said, suggests that plan administrators must accord special deference to the opinions of treating physicians.

Moreover, the court said, ERISA does not impose a heightened burden of examination on administrators when they reject a treating physician's opinion.

Plan administrators, the court said, may not arbitrarily disregard a claimant's reliable evidence, including the opinions of treating physicians.

However, courts have no warrant to require administrators to automatically accord special weight to the opinions of treating physicians, the high court added.

Moreover, the Supreme Court said, lower courts may not impose a burden of explanation on plan administrators when they give credit to reliable evidence that conflicts with a treating physician's evaluation.