Published on:

INSURER AGREES TO REINSTATE ERISA LTD INSURANCE BENEFITS

The Standard Insurance Company recently agreed to reverse its decision to deny LTD benefits to a client of the firm who had ongoing and persistent back problems. The Standard denied the claim ostensibly because “the medical records do not provide substantiation of a significant Physical or Mental Disease process which would render you Disabled.”

The client subsequently underwent a “Right-sided PLIF L5-S1 with Thompson cage, local bone, Vitoss, bone marrow aspirate right-sided transpedicular nerve root decompression L5 and S1, bilateral fusion L5-S1 with mantis instrumentation.” Even after the surgical records were provided by the client the Standard maintained its denial. The client then hired SMDA to pursue her final (and voluntary) appeal.

SMDA filed an administrative appeal of the denial decision and provided additional documentation further establishing the clients inability to perform her own occupation. Key among this was a more detailed explanation of her condition provided by the attending orthopedic surgeon who actually performed the extensive back surgery.

This case illustrates the importance of compiling a comprehensive and detailed administrative appeal. Had the Standard refused to overturn the denial decision we felt comfortable that the administrative record would have favored the client’s claim should a lawsuit been needed.