Northern California Court Rejects Treating Physician Rule in ERISA Case

On Friday, Judge Jeffery White rejected Pamela Jackson's requests for long term disability benefits from her employer under the Employee Retirement Income Savings Act of 1974 (ERISA).

Ms. Jackson worked as a help desk analyst for the law firm of Wilson, Sonsini, Goodrich & Rosati until December 17, 1997 when she left work due to numbness and pain in her lower back.  In March 1998, she applied for and received long term disability benefits.  Shortly thereafter, she underwent back surgery and for the following year, her physician documented steady progress recommending she return to work in March 1999.  However, Ms. Jackson had complained of back pain in September 1998 and stated that it continues to this day. Her treating physician, who also performed the surgery on her stated that tests "failed to account for self reported symptoms."  Her appeal of the termination of benefits was denied in March 1999.  Sometime later, in July 2003, her doctor stated that Ms. Jackson was 100% disabled and unable to return to work perhaps because of an erroneous needle injection.

Prudential Insurance Company of America, who administered the plan, had several physicians who evaluated Ms. Jackson, each time they stated that she had no objective symptoms.  Under the plan, in order to receive long term disability benefits the claimant needed to have an objective injury which prevented her from doing her major job duties.

With regard to the disagreement by physicians, Ms. Jackson stated that her expert should be given more credence under the "treating physician rule."  As explained in Regula v. Delta Family-Care Survivorship Plan (9th Cir. 2001):

The treating physician rule applied in the Social Security setting requires that the administrative law judge ("ALJ") determining the claimant's eligibility for benefits give deference to the opinions of the claimant's treating physician, because "he is employed to cure and has a greater opportunity to know and observe the patient as an individual."

However, the U.S. Supreme Court saw things differently a few years later, in Black and Decker Disability Plan v. Nord (2003).

[C]ourts have no warrant to require administrators automatically to accord special weight to the opinions of a claimant's physician; nor may courts impose on plan administrators a discrete burden of explanation when they credit reliable evidence that conflicts with a treating physician's evaluation.

The plan administrator was free to chose the independent physicians opinion.  The judge found that reasonable under what I call the "Katy Perry Rule." In her song, Hot 'n Cold Ms. Perry states, "You change your mind like a girl changes clothes...you overthink [and] always speak cryptically [therefore] I should know that you're no good for me." Similarly, witnesses who later change their mind are unreliable.

The case is Shoenmann ex rel Jackson v. Wilson, Sonsini, Goodrich, & Rositi et al. No. C 08-1607.  The opinion is below the fold.



Here is the opinion:

Jackson v. Wilson Sonsini