The attorneys at SMDA recently convinced long term disability insurer, Cigna to reverse its decision to deny an Oakwood Hospital employee  disability insurance benefits when the claim transitioned to the “any occupation” standard.

As with most LTD insurance policies this Cigna policy paid benefits for 24 months if the claimant could not perform the material and substantial duties of her own occupation at a local hospital (Henry Ford).  Cigna denied her claim when the definition of disability changed to “any occupation.”

SMDA filed a comprehensive administrative appeal of the adverse benefit decision explaining in detail why the client’s combination of significant medical conditions prevented her from performing the duties of even a sedentary occupation.  SMDA was able to provide significant documentation including a favorable SSD decision along with a number of objective test results confirming both her multiple medical diagnosis and the basis for her significant pain and functional limitations.

The 5th Circuit Court of appeals recently reversed a ruling for a worker suffering from Reynaud’s Disease, which is a condition preventing the claimant from working in a cold environment.  Unfortunately, the claimant worked at a chicken processing plant as a Hazard Analysis coordinator.  Her job duties required  that she inspect each part of the processing plant, including the refrigerated sections where the temperature was maintained at approximately 40 degrees.  The LTD insurance policy provided benefits if she was disabled from  “performing the duties of her Regular Occupation.”  Reliance Standard, the Long Term Disability Insurer, denied the claim based upon an in-house vocational reviewer who concluded her regular occupation would be classified as a “Sanitarium” as defined by the DOT and that the material duties “include neither employment at a poultry processing plant nor exposure to the cold.”   Utilizing an abuse of discretion standard the Appellate court overturned the lower court’s decision for the claimant.

This is just one more in a very long line of cases demonstrating the difficulty claimant’s face in pursuing ERISA claims for Long Term Disability Insurance benefits.  And, in my opinion, the inherent unfairness in the current state of the law.

SMDA was hired by a Michigan family to compel an insurance company to pay Long Term Care benefits for their elderly mother who had been receiving care at a Long Term Care facility.  The family had purchased an insurance policy to help defray the cost of care for their mother who had developed a number of age related medical problems including Alzheimer’s.  The insurer initially agreed to pay the daily benefit but changed course rejecting the claim alleging that their mother  no longer met the policy requirements because it claimed she was capable of performing most of her activities of daily living unassisted.

After reviewing the medical records from her doctors and the long term care facility SMDA filed suit against the Insurer for its breach of the insurance contract.  As a result of the litigation, the Long Term Care Insurer agreed to pay all of the past due benefits as well as refund the premiums that were paid after the wrongful denial of benefits.  Regular readers of this blog will recognize this as a bit of an outlier as it is not a claim for Long Term Disability Insurance nor does it involve the ERISA statute.  However, we were happy to help this family obtain the Insurance benefits that they had paid for and that will allow their mother to continue to receive the quality of care she needs in her time of need.  If you have a claim for Long Term Care benefits that you believe was wrongfully denied or terminated, please feel free to give SMDA a call to discuss.

SMDA recently obtained a reversal of CIGNA’s decision denying Long Term disability Insurance Benefits to a Henry Ford Hospital employee.  As a result of our comprehensive administrative appeal CIGNA (aka Life insurance Company of North America) overturned its decision denying our client’s claim for benefits.  Our client suffered from a number of conditions including Type 2 Diabetes Mellitus, Neuropathy, Asthma, COPD, Arthritis, and carpal tunnel syndrome. We convinced CIGNA to reinstate the disability insurance benefits even under the more stringent “any Occupation” definition of disability.

Many of our client’s think that they are entitled to Long Term Disability Insurance benefits because they are no longer able to do their job as a result of an illness or injury.  What they don’t understand is that the Disability Insurance companies have fabricated a hurdle that can  sometimes be impossible to clear.  A recent case out of Florida provides a good illustration.  In McCook v Aetna the court rejected the claim finding:

“Aetna was entitled to rely on the Dictionary of Occupational Titles (“DOT”) to determine how McCook’s occupation was normally performed in the national economy. See Cook v. Standard Ins. Co., No. 6:08-cv-759- Orl-35DAB, 2010 WL 807443, *9-10 (M.D. Fla. Mar. 4, 2010) (stating that defendant “was entitled to rely on the DOT’s classification exclusively” for its “own occupation” determination, where the plan allowed defendant to “look at the way the occupation is generally performed in the national economy”). The Court agrees with the findings of the Magistrate Judge which conclude that “[t]he additional duties and demands described by Plaintiff appear to be products of her particular work setting at [Bank of America], not her occupation as generally performed in the national economy.”

Basically, the court agreed with Aetna that because of how the plan defined  “Own Occupation” the disability insurance company could just ignore the claimant’s actual job duties for her employer.  This is a good example of why  it can be critically important to understand how the insurer may attempt to re-characterize your occupational duties in a Long Term Disability Insurance claim.

It can be confusing trying to figure out the amount of Long Term Disability Insurance benefits the insurance company should pay.  Here is a brief outline of how the amount is commonly determined.

Step 1.-Figure out your base monthly income.  (Take your yearly income and divide by 12.  Beware however-commonly excludes overtime and bonuses.)

Step 2.  Multiply by the benefit percentage listed in the Insurance Policy.  Commonly 66 2/3%.  (However, I have seen many other rates from 40-70%.)

The team at SMDA recently obtained a favorable administrative decision reversing Cigna’s (Life Insurance Company of  North America) decision denying disability insurance benefits for a Registered Nurse who had been disabled by her treating physicians as a result of  her significant orthopedic (back and shoulder) problems.  The original denial was based primarily on the fact that the claimant was neurologically intact with normal strength and reflexes indicated in the treating medical records.

SMDA prepared a comprehensive administrative appeal including disability statements from the client and her treating physicians, medical records and peer reviewed medical journal articles.  We were able to establish that an individual with normal strength and reflexes may still suffer from disabling pain which interferes with their ability to perform the material and substantial duties of their occupation as a Registered Nurse. The disability insurance company overturned the denial decision retroactively reinstating the disability benefits and placing the client back on claim.

 

SMDA recently convinced  LTD insurer Cigna to overturn its claims denial decision for a registered nurse who developed significant low back pain that prevented her from performing her own occupation.  Our client had degenerative disc disease that had progressed over the years eventually leaving her unable to work.  Cigna initially denied her claim finding she was not disabled.

SMDA filed a comprehensive administrative appeal which established that the functional limitations the client experienced made it impossible for her to perform the material duties of her own occupation.  Cigna overturned the claims denial decision and agreed to retroactively reinstate her LTD benefits and put her back on claim.

SMDA recently convinced Cigna (Life Insurance Company of North America) to overturn a claims denial decision for an individual who is suffering from significant cognitive deficits as the result of some as yet undiagnosed condition.

SMDA prepared a comprehensive administrative appeal of the claims denial decision including neuropsychiatric testing which demonstrated significant deficits in various cognitive domains which clearly preclude the insured/client from performing the duties of his own (or frankly any occupation).

We applaud Cigna for making the right decision on this claim and reinstating our clients Long Term Disability benefits.

Almost every Long Term Disability Insurance Policy I have ever reviewed contains a limited period (usually 24 months) of time that it will pay benefits if a claimant is unable to perform the duties of his/her “Own” (see prior post on how “Own” occupation is misleading) occupation. The plans most commonly contain a change in the definition of disability from “Own”occupation to “Any” occupation after the 24 month period runs. So, after 24 months the claimant must be able to establish that they are unable to perform the duties of “Any” occupation in order to continue to receive benefits. A few caveats-there is also usually a qualifier for “Any” occupation that the claimant may be qualified to perform the identified occupation by education, training or experience. There is also usually an earnings qualified that the identified “Any” occupation must usually pay some percentage (commonly 60 or 80%) of the claimants “Own” occupation.

We see many claims where the Long Term Disability insurer refuses payment past the 24 month “Own” occupation period by identifying some less demanding occupation it asserts the claimant can perform.