Articles Posted in LTD Case Examples

Published on:

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:

Published on:

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:
Continue reading

Published on:

The US District Court for the Eastern District of Michigan recently determined that LTD Insurer-MetLife wrongfully denied a claimant’s request for LTD benefits.

SMDA was retained by the claimant after her administrative remedies had been exhausted and suit had been filed. The client had been employed as an Audit Manager for Deloitte LLP when she developed a condition which caused orthostatic intolerance which resulted in unpredictable and intermittent dizziness and fainting spells. Her own doctors said that when these episodes occurred she must be able to lie down during the day.

MetLife obtained a paid paper review by an outside physician who determined that the Insured “may need to sit or lie down as needed.” Relying on this recommendation, MetLife’s in-house vocational reviewer then concluded that the claimant was capable of performing the duties of her own occupation because her employer would allow her to “sit as needed.”

Applying a deferential standard of review, the Court determined that MetLife’s denial decision was arbitrary and capricious:
Continue reading

Published on:

SMDA recently convinced Long Term Disability Insurer Cigna to reverse its original claims denial decision by filing a comprehensive administrative appeal.

SMDA was retained by a very nice client who was having significant mental health problems that were significantly aggravated by stress. The client retained our firm after Cigna rejected her claim for LTD benefits but prior to the expiration of the 180 day period she had to complete her administrative appeal. The ability to appeal the claims denial decision within 180 days is required by the ERISA statute and regulations.

Upon consideration of the administrative appeal Cigna overturned the claims denial decision and retroactively reinstated the clients LTD benefits. The client received a lump sum for the past due benefits and will continue to receive monthly benefit checks so long as she continues to meet the policy’s definition of disability during the 24 month pay period for mental health problems.

Published on:

SMDA recently convinced Long Term Disability Insurer, Lincoln Financial Group, to reverse its decision to deny Disability Benefit payments to a Physician.

Our client had developed a degenerative orthopedic condition that resulted in several joint replacement surgeries. Lincoln Financial voluntarily paid Total Disability benefits while the client was recovering from each of the surgeries.

However, when the doctor returned to work he was only able to resume a part time schedule. Lincoln Financial rejected the physicians claim for additional benefits asserting that he was no longer Totally Disabled. However, upon examination of the Plan document it became apparent that the policy provided for Partial Disability benefits. SMDA convinced Lincoln to reverse its claims denial decision by filing a comprehensive administrative appeal analyzing the Plan language as well as the clients ongoing restrictions and limitations.

Published on:

SMDA recently convinced an LTD insurer to overturn its claims denial decision by filing a comprehensive administrative appeal on behalf of our client. SMDA’s client had filed a claim for disability benefits as a result of serious depression and anxiety. The LTD insurance company originally denied the claim contending that since the claimant was still able to care for her profoundly disabled teenager she was not entitled to disability benefits.

SMDA successfully pointed out the fallacy of this argument convincing the insurer to retroactively reinstate the disability benefit claim and put the client back on claim.

Published on:

Lincoln National Life recently overturned its decision to deny an SMDA client’s claim after we filed an administrative appeal of Lincoln’s claim’s denial decision.

Our client had worked for FoMoCo for more than a decade when the facility where she worked was sold as part of a corporate restructuring. She had ongoing health issues which had previously resulted in a leave of absence and a claim for LTD benefits which had been approved and paid by the prior LTD carrier.

After the sale occurred she returned to work for a period of time. During this time the new employer changed disability insurance carriers to Lincoln National Life. When the client experienced a recurrence of her prior problem she filed a claim for benefits with Lincoln National.

Published on:

SMDA prepared a comprehensive administrative appeal on behalf of a gentleman who had been forced to stop working as a press operator as a result of ongoing orthopedic problems with his neck. He had underwent cervical discectomy surgery as a result of his serious neck pain and radiculopathy. The surgery was only partially successful leaving him with residual pain and problems.

Despite his ongoing problems he attempted to return to work. He was only able to work for a brief period of time before his activity significantly aggravated his pain. Cigna originally denied his claim for benefits after a paper review which determined that he could perform the duties of his medium demand occupation.

SMDA filed an administrative appeal of this denial decision explaining in detail the various flaws in the conclusions of the paper reviewer. Cigna agreed and overturned the claims denial decision. The clients LTD benefits will be retroactively reinstated and he will be placed on claim.

Published on:

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.

Published on:

SMDA was fortunate enough to receive another favorable decision from the federal court finding that the Long Term Disability insurer again wrongfully denied our client’s claim for benefits.

In Deloach v. The Great Atlantic & Pacific Tea Company (A&P) the Judge reversed the claims denial decision finding that the client was disabled as a result of his medical condition. The Court rejected the Defendant’s request to review the case utilizing a discretionary standard of review. Instead, the Court agreed with our argument that the plan documents failed to properly assign any discretionary authority to the entity that actually made the claims denial decision. (Cigna) This is a prime example of why obtaining the proper standard of review is absolutely critical in a case for ERISA governed LTD benefits.

This is the second time this matter has been litigated as the Defendant’s initially denied the claim during the “own occupation” benefit period. SMDA had previously brought suit and convinced the Court to reinstate benefits. The Court ordered a remand for consideration of benefits during the “any occupation period.” This second suit was instituted when the claim for “any occupation benefits” was denied.