Articles Posted in LTD Case Examples

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.

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.

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.

SMDA was hired by an employee of ArvinMeritor when her claim for Short Term Disability benefits was rejected. The client had suffered a fractured coccyx in a slip and fall and overtime was eventually diagnosed with Fibromyalgia and Depression. Despite the universal support of each of her treating physicians her employer rejected her claim for benefits upon the recommendation of the third party disability benefits administrator, Cigna.

After SMDA filed suit the case was submitted to private arbitration with a retired Circuit court judge. The Judge agreed with our argument to apply a De Novo standard of review because of the manner in which the claim was handled which was critical:

Because the Plan does not authorize the delegation of the Plan Administrator’s discretionary authority, LINA’s determinations with respect to Claimant’s claim for benefits under the STD provisions of the Plan are subject to de novo review.

In another recent SMDA victory, the Federal Court overturned Metropolitan Life Insurance Company’s decision improperly under-calculating the claimants LTD benefits. In Gray v. Metlife the Court found that Metlife had wrongfully excluded the claimants “Health and Welfare” pay from his “base monthly earnings.”

The Court determined that the ERISA claim should be reviewed De Novo since the policy was amended after March 1, 2007 when the State of Michigan banned the use of discretionary clauses. This is one in a number of cases confirming this important issue.

Reviewing the policy language the Court found:

SMDA received a favorable decision overturning Mutual of Omaha’s decision to terminate our client’s short term disability benefits. The firm represented a casino dealer who developed severe psoriasis of the hands as well as depression and anxiety stemming from her witnessing a gambler commit suicide by shooting himself at her table.

She filed a claim for benefits which was initially approved. Mutual of Omaha obtained a paper review of her file and terminated her benefits despite the in-house reviewers request that the Insurer obtain her prescription records.

The Court reversed the denial decision utilizing a De Novo standard of review finding that the client was in fact disabled and criticizing the Insurer for failing to obtain a medical examination while questioning the credibility of the claimant and her treating physicians. Gray v Mutual of Omaha, Case No. 11-15016 (ED Mich)

Mr. Z was employed by the public works department of a local municipality. Initially, his LTD insurer approved and paid his claim for LTD insurance benefits finding he was Totally Disabled. After paying benefits for 24 months, the Insurance Company denied Mr. Z’s claim “because there is no medical evidence substantiating the fact that you are unable to work in a sedentary occupation.” Mr. Z then hired SMDA.

SMDA prepared an administrative appeal confirming Mr. Z has been diagnosed with degenerative disc disease, L3-4 disc herniation impinging the Left L3 nerve root, L4-5 disc bulge with annular tear, L5-S1 diffuse disk bulge with annular tear to the left with impingement of the bilateral nerve roots. As a result, he had severe back pain on a daily basis. His back pain was aggravated by any physical activity. As a result of his medical condition and the severe and disabling back pain it caused he was unable to sit or stand for any period of time. As a result, he was unable to perform the material duties of any occupation, which involve sitting, standing, walking, lifting or carrying. Mr. Z was also approved for Social Security Disability benefits.

SMDA was recently able to reach a pre-lawsuit settlement with Mr. Z’s LTD insurance carrier which included the resolution of all future benefits. In other words, the insurance company paid a significant sum of money for both Mr. Z’s past due benefits and his future benefits. This type of settlement has numerous advantages, not the least of which is to terminate the need for the client to have any future contact with the LTD insurance company. The claim settled pre-suit in large part because the insurance company realized that it likely faced an adverse court decision due to the administrative appeal prepared by SMDA. If you have a claim for LTD benefits that has been recently denied give SMDA a call to see if we can help.