Guardian Ordered To Pay Disability Benefits to Neuro-Ophthalmologist

Sometimes our clients who are physicians diagnose and self-treat their conditions and ask us whether they can establish their disability claim based on their own assessment.  It stands to reason that an insurance company asked to pay benefits will not rely solely on the word of the claimant. In fact, most policies indicate not only that the claimant has to be under “appropriate care” for their condition, but they cannot be treated by a family member.  Weisman v. The Guardian Life Ins. Co. of Am., Civil Action No. 7:22-cv-00595, 2024 U.S. Dist. LEXIS 2807  (W.D. Va. Jan. 5, 2024).is interesting because the court held that Dr. Weisman, neuro-ophthalmologist and ophthalmic surgeon who experienced tremors and self treated for years was eligible for disability benefits even though he had not seen a doctor just before stopping work in Dec 2021.   The court concluded that whether or not Dr. Weisman met the policy requirement that he be under the regular care of a doctor during his disability was not relevant because the court agreed with Dr. Weisman that he had reached his maximum point of recovery and was  disabled before the policy ended.   The court relied on the opinion of a specialist, who examined Dr. Weisman after the fact and stated that he had received the appropriate care for his disability.

Finally, the court rejected Guardian’s contention that there was inadequate evidence that Dr. Weisman was disabled before he quit his job because he was self-evaluated (and treated) up to that point and only went to the specialist after he stopped working. This ERISA claim turned on whether he was covered under the policy even though he sold his business as of the date of his disability. .

We at Bonny G. Rafel LLC, provide legal counsel to individuals seeking to obtain (or overcome the denial of) long term disability benefits, and advocate for our clients as the Voice of the Disabled.  See our website for video presentations and information on our boutique practice and contact us to discuss your case.


Contact Information