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'Unexplained Gap' in Reviewing Physician's Opinion Results in Decision for ERISA Plaintiff
Health Plan Law
[Guidance Overview] Oct. 29, 2008
Excerpt: The Fifth Circuit carefully noted that the reviewing physician, though finding the claimant not disabled, failed to engage the opinion of the treating physician on the key points offered in justification of the disability claim.... The 'unexplained gap' resulted in a substantial defect in the reasoning of the plan administrator's benefit denial. The Court reversed the decision of the district court and remanded for entry of judgment in favor of the claimant.
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