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Medical Reviews for Disability & Life Insurance Claims

In most disability and many life insurance claims insurance companies and plans hire doctors to review the claimant's medical records. First Circuit case law is favorable for the proposition that such doctors' opinions are only as good as the reasons they give, and when the reasons are not factually supported, the opinions cannot be relied upon to support the decision.

Standard of Review in ERISA Cases

A threshold issue in every ERISA case is the standard of review. Most insurance policies and plans reserve discretion for the plan and thus review is for abuse of discretion. When the policy or plan does not reserve discretion or when saved-from-preemption state law bars application of a discretionary clause, the review is de novo. When a review is for abuse for discretion a court defers to the plan or insurance company's decision unless it is unreasonable - a difficult standard to overcome. It is therefore important to obtain discovery demonstrating that the plan or insurance company's discretionary decision was affected by its conflict of interest. For example, an insurance company which both decides and pays a claim has an obvious conflict of interest because any time it rules of favor of the claimant it costs the insurance company money. While the First Circuit has not prohibited discovery on conflict of interest issues, it seems reluctant to allow the nature and extent of such discovery necessary to explore conflicts of interest properly. So, when discovery is necessary to explore conflicts of interest, at least for now, the First Circuit may not be the best place for your case.

Areas Served by the First Circuit

Our ERISA attorney serves the First Circuit by representing claimants in the following states and cities: Massachusetts: Boston, Worcester, Springfield, Lowell, Cambridge, New Bedford, Brockton, Quincy, Lynn and Fall River; Maine: Portland, Lewiston, Bangor, Auburn, Biddeford and Waterville; New Hampshire: Manchester, Nashua, Concord, Dover, Rochester and Keene; Puerto Rico: San Juan, Bayamon, Carolina, Ponce, Caguas, Guaynabo and Mayaguez; and Rhode Island: Providence, Kent, Washington, Newport and Bristol.

Call an ERISA Lawyer at (844) 710-2993

If you would like to talk about the services we provide and how we can help with your disability or life insurance claim, please feel free to call our offices. We are available 24 hours a day, 7 days a week to take your call, and we offer a free consultation to discuss the ways we may be able to assist you.