Michigan Long Term Disability Insurance Lawyer Blog

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.

Related Posts: SMDA convinces LTD Insurer to reverse claims denial decision for Cognitive Issues, Court rejects Cigna’s denial of claim by paralyzed claimant, 6TH CIRCUIT COURT OF APPEALS OVERTURNS AETNA”S LTD DENIAL DECISION, FEDERAL COURT FINDS METLIFE ABUSED ITS DISCRETION-ORDERS INSURER TO PAY LTD BENEFITS

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.

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.