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I was recently asked to review a claim denial by a well know disability insurer for a nice lady who suffered a terrible crush injury  to her foot.  She had worked at a production facility where her job duties required her to be  on her feet for extended parts of the work day.  Her employer was not able to accommodate her standing restrictions so she filed a claim for LTD benefits with Lincoln Financial.  The Lincoln policy defined her “Own Occupation” as a collective description of related jobs, as defined by the US Department of Labor Dictionary of Occupational Titles.  It includes any work done for pay or profit, regardless of: 1. whether such work is with the employer, or some other firm…; or 2. whether a suitable opening is currently available with the Employer or in the local labor market.”

Despite the fact that her employer would not allow her to return to work if she was unable to stand for extended periods of time, Lincoln’s in-house vocational consultant determined that her Occupation was best defined as a Project Planner.  Lincoln then denied her claim for benefits finding that her “Own Occupation” could be performed sitting most of the time at some other employer. Since she had already exhausted her administrative remedies we were unable to offer any evidence to supplement the record.

This is a classic example of the difficulty with LTD claims.  The insurers policy language allows them to disregard the actual duties of a claimant’s own job in favor of some imaginary “collective description of related jobs” which, in effect, turns logic on its head.  Even though your own employer specifically says you must be able to stand for 80% of the day, Lincoln says “your occupation” can be performed sitting most of the time.

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In this recent case out of Louisiana the court rejected Cigna’s (Life Insurance Company of North America) efforts to deny a claim by a man who was permanently paralyzed and wheelchair bound. The claimant, Mr. Hughes, had been employed as an electrician when he was forced to stop working as a result of his paralysis.  While Cigna initally approved his claim for LTD benefits in 1999, what followed was very troubling.

Despite the fact that he was permanently paralyzed and wheelchair bound, Cigna denied his claim for benefits on at least 4 different occasions.  The last denial because he “failed to provide requested documentation.”  After the last denial Mr. Hughes failed to file an administrative appeal within 180 days as the denial letter advised.  When he finally did appeal, Cigna denied the appeal as untimely.

Mr. Hughes hired an attorney who filed suit claiming that the actual Insurance Plan did not mandate an appeal within 180 days.  The Court agreed rejecting Cigna’s argument that Mr. Hughes administrative appeal was untimely.  The Court then found:

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A US District Court Judge recently granted a motion filed by SMDA granting LTD benefits to one of our clients.  The Court found that the third party administrator had abused its discretion in recommending a denial of benefits.  The Court found that the client’s serious back problems along with the multiple powerful pain medications prevented him from performing the duties of his own occupation.

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SMDA partner, Patrick Derkacz, recently recovered $1.2 million dollars on behalf of his seriously injured clients.  Mr. Derkacz convinced State Farm to pay this significant settlement the day after taking the deposition of the at-fault driver who offered testimony  that he was not responsible for causing this rear end accident.  The at-fault driver tried to blame everyone but himself, including the seriously injured driver of the car he struck for not traveling the minimum speed on the freeway.  (The  freeway traffic was slowing to a stop for a previous accident!)  State Farm likely realized that any potential jury would not look kindly upon Defendant’s ridiculous testimony.

This significant recovery should help the elderly couple injured in the crash the economic cushion they need to live their lives as they wish.

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Anyone familiar with LTD Insurance claims and ERISA knows that you must first exhaust your administrative remedies before filing suit. In other words, you have to try and convince the LTD insurer to reverse its decision to deny the claim for benefits. While this may seem like an difficult task since the LTD insurer who makes the claims decision is the same entity that pays the claim, it is not impossible.

SMDA has been fortunate to convince CIGNA to reverse its LTD claims denial decision in several consecutive recent claims.

The first client was experiencing significant back problems as a result of degenerative disc disease. She was unable to continue her job as a customer service representative for a dental services company. The second client had a number of medical problems including pretty severe carpal tunnel syndrome which caused problems with any repetitive hand movements. Unfortunately, she was unable to do her job which required non-stop typing.

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SMDA recently convinced Cigna to overturn a claims denial decision by filing a comprehensive administrative appeal of the LTD claims denial decision.

SMDA was hired by a client who worked for Norwegian Cruise Lines who developed significant back problems. His back problems became so severe that he was put off the ship by the ship’s doctor and shortly thereafter underwent back surgery. He did his best to return to work but continued to experience significant problems. The ship’s doctor again discharged him from the ship.

Despite this information, CIgna originally denied his claim for LTD insurance benefits. SMDA convinced Cigna to reverse its denial decision after obtaining, reviewing and analyzing the voluminous medical records and explaining why he continued to satisfy the insurance policy’s definition of disability.

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While this blog is normally devoted to all things Long Term Disability, I wanted to give a shout out to my legal partner, Phil Serafini who obtained an outstanding result in a automobile no-fault case.

SMDA was contacted by the mother of a minor who was involved in a serious one car MVA on 7/23/12 one day before a lawsuit had to be filed to force their car insurance company, Home – Owners, to pay her daughter’s Michigan No-Fault Insurance Benefits. Their insurance company denied the claim because at the time of the MVA, the client was 15 years old and driving, contrary to Michigan law, without a parent in the car and her mother had given a statement to Home-Owners that her daughter did not have permission. Her father allegedly made a comment at the scene that could be construed as meaning that his daughter did not have permission as well.

The primary issue for trial was whether the minor had her parents’ permission to take their car on the date of the MVA. If she had taken the vehicle without permission, she would be barred from no fault benefits under MCL 500.3113(a). Her mother testified at trial that Alison had permission and that she wasn’t initially truthful with the Home-Owners adjuster as she was concerned she could go to jail as the owner of the vehicle and be unable to care for her catastrophically injured daughter. Her father testified at trial that Alison had permission the day of the MVA and that he didn’t recall the alleged statement at the accident scene. However, if such statement was made, it would have been directed towards her mother as he initially disagreed with her decision to let Alison take and operate the vehicle without a parent present. Alison’s discovery deposition, now deceased, was read at trial. She also testified she had parents’ permission to regularly take and use the car before and on the date of the MVA.

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A panel of the 6th Circuit Court of appeals recently overturned Aetna Life Insurance Company’s decision denying LTD benefits to one of our client’s. In Mckenna v Aetna Life Insurance Co. the court found that Aetna improperly rejected our client’s claim for benefits.

In sum, although it is Appellant’s burden to prove that she was entitled to LTD benefits, she unquestionably met that burden when she proved to Aetna’s satisfaction that her condition resulted in functional impairments that prevented her from performing the material duties of her own occupation through February 23, 2013.

The court explained:
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In a case mentioned previously on this Blog, a Long Term Disability Insurer (MetLife) reversed its claims denial decision upon remand from Federal Court.

The client last worked in 2009 and can expect more than five years of past due benefits. This is an unusual circumstance for a case with a long and twisting procedural history.

The client originally came to SMDA while represented by another law firm while she was facing a motion to dismiss her case based on the statute of limitations. SMDA agreed to take her case and won the motion to dismiss-convincing the Court that the language of MetLife’s LTD insurance policy was ambiguous in explaining when she had to file suit to preserve her claim.

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While this Blog is usually devoted to issues involving LTD claims and cases, I felt I needed to go off topic for a minute.

The Michigan Supreme Court issued a decision this past week in a case where a disabled young man drowned in a public swimming pool. Investigation revealed that the lifeguard on duty was distracted, not in his designated position, and ignored several calls for help from another student who saw the disabled young man under water.

In an opinion written by (Justice) Brian Zahra the Court dismissed the claim finding that the lifeguard’s failure to act was not the proximate cause of the young man’s death even though timely action might have prevented his death. Instead, and I am not making this up, the Court determined the proximate cause of death was “that which caused him to remain submerged in the deep end of the pool without resurfacing.”