Articles Posted in LTD Case Examples

SMDA was contacted by a physician to evaluate a repayment request by a well known Long Term Disability Insurer.  The doctor had been diagnosed with a medical condition which interfered with the surgical aspects of his practice.  The disability insurer convinced the doctor that he was only residually disabled and intermittently paid a residual disability benefit whenever he had a qualifying loss of earnings each month.  The Disability insurer took this position because the doctor continued performing a portion of the office-based tasks associated with his specialty.  This went on for more than 5 years. Eventually the disability insurer requested repayment when it determined that it had mistakenly overpaid benefits for several months.

Upon investigation, counsel determined that the physician actually was totally disabled under the several policies he had in place which were purchased when he completed his residency several decades earlier.  (In counsel’s experience, the older the policy the better the language is for the claimant.)  SMDA also learned the physician/client actually had multiple disability policies with several different Long Term Disability insurers.  Counsel was able to favorably resolve the doctor’s  claims with each of the LTD Insurers.  All because of the disability insurer’s  initial repayment request.

If you are a physician who has been forced to curtail the nature of your practice but your disability insurer has refused to honor your claim for Total Disability benefits please contact SMDA for a free consultation.

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.

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.

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 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.

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:

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:

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.”

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.

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.