Articles Posted in LTD Case Examples

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.

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.

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.