SMDA was able to negotiate a favorable settlement for a Deloitte manager’s claim for Permanent and Total Disability benefits after a tortuous claim process. The injured client retained SMDA after an unsuccessful application for benefits. Her disability benefit claim was significantly hampered because she waited several years to hire a lawyer while her claim languished waiting for a decision. After Mutual of Omaha finally denied her claim (after years had elapsed) SMDA was hired and filed a comprehensive administrative appeal. Suit was filed shortly after the appeal was denied. Counsel was able to craft several persuasive arguments that the statute of limitations had not expired despite the passage of so much time which convinced the insurer it would be best served to settle the case. The case was further complicated by the nature of the disability-a traumatic brain injury.
We have started getting calls for disability claims related to the Covid-19 pandemic. Most LTD insurance policies have an elimination period of either 90 or 180 days which mandate that you be continuously disabled for this period of time in order to be eligible for long term benefits. The duration of many short term disability insurance polices will correspond with the elimination period of the LTD policy. (i.e. STD will pay for 90 or 180 days) Given the nature of the pandemic there are a significant number of people who have become gravely ill with this disease. We would encourage you to make sure that you timely apply for both Short and Long term disability insurance if available to protect your family from the financial impact of the pandemic.
At Serafini, Michalowski, Derkacz & Associates, P.C., one of our areas of expertise is representing and fighting for those who have been injured as a result of a motor vehicle collision, whether that be against your own personal insurance company or the person whose negligence caused the collision in the first place.
On June 11, 2019, the Governor of Michigan, Gretchen Whitmer, approved and filed with the Secretary of State Act No. 21, Public Acts of 2019, commonly referred to as No-Fault Reform. Based upon our years of experienced and reading of the new law, we want to offer our guidance regarding your coverage choices as you are no doubt receiving information from your automobile insurer about renewing your policy, and the options at your disposal.
This legislation has brought significant changes to the Michigan No-Fault Act, which is the law that governs Michigan automobile insurance and the rights and duties of those Michigan residents who own and drive vehicles on our highways, as well as those who are unfortunately involved in a motor vehicle collision. You should understand that these changes only relate to the portions of your automobile insurance policy relating to Personal Injury Protection (PIP) benefits in the event you are injured in an accident.
In compliance with the governor’s order regarding shelter in place and stay safe at home policies, the firm has implemented the following policies consistent with Executive Order 2020-21.
Pursuant to Section 4 paragraph (b) the firm has identified its essential employees necessary to conduct minimal business transactions, like banking, payroll processing, employee benefits and ensuring that those of us that are working from home have the ability to work remotely. Each designated employee has a “transit letter” within his or her possession.
For compliance with the executive order the following information is available:
We are closely tracking the rapidly evolving public health and community concerns related to the new coronavirus or COVID-19. Rest assured that we are taking all available steps to remain accessible to our clients as we continue to act in accordance with their best interests during this difficult time.
Please see below for answers to some frequently asked questions, and feel free to reach out to us any time at firstname.lastname@example.org or 586-264-3756 for assistance with your legal matter.
Is your office currently open during normal business hours? No. Although we will have staff present intermittently through the week.
SMDA recently convinced disability insurer Lincoln National Life Insurance Company to overturn its decision denying disability benefits for a client who was working as a Computer Support Technician. The client had developed serious orthopedic problems which resulted in significant functional limitations. SMDA filed a comprehensive administrative appeal demonstrating the client’s inability to perform the actual duties of his own occupation. This is a prime example, especially in claims governed by the Employee Retirement Income Security Act (ERISA), of the importance of getting legal counsel involved early in the process to short-circuit any effort to deny a claim for disability benefits. Remember that the disability insurance company is inherently conflicted as it both determines eligibility and then must pay benefits if the claim is approved.
Registered Nurses have an incredibly demanding occupation. As a result we have seen many prospective RN’s who have suffered some form of orthopedic problems which unsurprisingly prevent them from continuing to provide direct patient care.
SMDA successfully appealed Cigna’s decision denying Long Term Disability Insurance benefits to our client who was forced to stop working as a registered nurse at Henry Ford Hospital due to her significant and progressive orthopedic spine problems.
SMDA filed a comprehensive administrative appeal with significant supportive documentation demonstrating the marked restrictions and limitations the client experienced as a result of her neck and back pain and problems. Cigna overturned the claim denial decision and retroactively reinstated the monthly disability payments to the original date fo denial.
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.