Opinion ID: 855794
Heading Depth: 2
Heading Rank: 1

Heading: Neaton’s Recovery Time

Text: Both Neaton and his treating dermatologist, Dr. Schuldenfrei, claim that it takes Neaton “a week or more” to recover following a Moh’s procedure. With respect to recovery time, Neaton stated: If the surgery was on my head or face by the third day my eyes swell shut for about five days . . . the Mohs surgeries I have are so large that the recuperation time can go weeks and sometime months. Right now I am still feeling effects of the past 3 surgeries which were months ago. Treating dermatologist Dr. Schuldenfrei agreed: The recovery time for Mr. Neaton following surgery of his skin cancers varies greatly. In the distant past, his lesions were less numerous and often very superficial, necessitating only several days for recovery. Over the past 2 years, however, his lesions have become increasingly aggressive (larger and deeper), necessitating more complicated surgery (Mohs surgical technique and plastic surgical reconstruction), with recovery times of a week or more. Hartford’s non-examining medical consultant, Dr. Petronic-Rosic, agreed in substantial part that “the multiple surgeries this claimant will most certainly need require approximately one week for reasonable recovery. Therefore, if he is to have surgeries once a month or every 2 months, a week off would be reasonable to enable adequate healing and obviate the need for bulky bandages to be able to work.” However, if Neaton were working from home, Dr. Petronic-Rosic opined that he would only require three to four days off work following surgery. Hartford adopted this finding without consulting Dr. Schuldenfrei or Neaton. -12- Dr. Petronic-Rosic did not examine Neaton. This is a relevant factor to consider, because a patient’s recovery time following surgery is variable and depends in part on the extent of a patient’s pain. Accordingly, the length of the patient’s recovery is in large part a credibility determination. Cont’l Cas. Co., 450 F.3d at 263-64 (holding that it was improper to rely on non-examining medical consultant to determine severity and credibility of pain). While it is not per se improper to rely on the opinion of a non-examining medical consultant, whether a doctor has physically examined the claimant is a factor that may be considered in determining whether a plan administrator acted arbitrarily in giving greater weight to the opinion of its consulting physician. Kalish, 419 F.3d at 508. The plan administrator’s failure to require a physical examination “may, in some cases, raise questions about the thoroughness and accuracy of the benefits determination.” Calvert v. Firstar Fin. Inc., 409 F.3d 286, 295 (6th Cir. 2005). Indeed, the lack of a physical examination may be particularly inadequate where, as here, the file reviewer makes critical credibility determinations. Id. at 297, n.6. This Circuit has repeatedly criticized the rejection of the opinion of a treating physician that is consistent with the medical record, in favor of non-examining file reviewers. See, e.g., Kalish, 419 F.3d at 509-510; Calvert, 409 F.3d at 297; Cont’l Cas. Co., 450 F.3d at 263.12 The obligation under ERISA to review the administrative record in order to determine whether the plan administrator acted arbitrarily and capriciously “inherently includes some review of the quality and quantity of the medical evidence and the opinions on both sides of the issues.” McDonald, 347 F.3d at 172. 12 Moon v. UNUM Provident Corp., 405 F.3d 373, 381-82 (6th Cir. 2005) (“[W]hen a plan administrator’s explanation is based on the work of a doctor in its employ, we must view the explanation with some skepticism.”). -13- In addition to the well-settled principle that a treating physician’s opinion is not entitled to any special deference under ERISA, Black & Decker Disability Plan v. Nord, 538 U.S. 822 (2003), Hartford maintains that Neaton cannot show that it disregarded the opinion of Dr. Schuldenfrei in favor of the opinion of Dr. Petronic-Rosic, a board-certified dermatologist with a sub-specialty in dermatose pathology, who provided an independent peer review of Neaton’s medical records. Specifically, Hartford points out that, because the Administrative Record contains no evidence that Dr. Schuldenfrei addressed the number of recovery days that Neaton would require if working from home, the argument that Hartford “arbitrarily. . . substitut[ed] the opinion of its hired, non-examining medical expert for that of Mr. Neaton’s physician as to the reasonable recovery time following a surgery” is not accurate. (Appellant’s Br. at 27). While we do not disagree with this analysis, Hartford misses the point. Hartford failed to obtain Dr. Schuldenfrei’s opinion with respect to Neaton’s recovery time if he were to work from home. If in fact the plan administrator were performing an appropriate review, he would have certainly obtained such information from the treating physician before proceeding to a final determination. Although the district court did not wholly disregard the opinion of Neaton’s treating physician, a court should not uphold a termination when there is an absence of reasoning in the record to support it. McDonald, 347 F.3d at 172. The number of days Neaton required to recover from a Moh’s procedure if working from home is in large part a credibility determination. See Calvert, 409 F.3d at 297. Hartford’s exclusive reliance on the opinion of a physician who never physically examined Neaton, or even spoke to him about his recovery process, calls into question the quantity and quality of the medical evidence and opinion. -14-