Disability Insurance Lawyer Blog

LONG TERM DISABILITY BENEFITS DENIED BY AETNA - SUCCESSFUL APPEAL

One of the elements of a successful long term disability claim is the ability to demonstrate regular medical care and a treatment regimen consistent with the disability. When examining a claim, long term disability insurance companies will look for a series of office visits, related tests, medications, and a treatment protocol that is consistent with the disability.

But not every patient follows the typical pattern of medical care and treatments, and this does not make them any less disabled. This is particularly so where the claim is predicated upon a mental or nervous condition or one involving the use of alcohol or drugs.

This was the situation faced by a high earning financial executive who came to us after his long term disability insurance claim was denied by Aetna. He was not able to work due to anxiety/depression and alcohol abuse. Aetna claimed that he was not disabled, since he was not under the regular care of his doctor. He was seeing a number of providers however, and we needed to piece together the treatment by multiple providers.

We secured his benefits by demonstrating that he was in fact maintaining continuity of care and seeing medical providers with enough regularity to satisfy the requirements of the policy. We argued that the decision Aetna had made had less to do with our client's treatment and more to do with the high value of his claim. The decision, like so many others that we see, was the result of an insurance company making a decision that was a result of a conflict of interest, acting in its own favor rather than that of the claimant.

Our client is now back on claim and is receiving monthly benefits.

If this sounds like your situation, call our offices today and learn how we can help.

FRANKEL & NEWFIELD WIN APPEAL AGAINST HARTFORD WHO DENIED BENEFITS TO A NURSE ANESTHETIST WITH HAND INURY

Our client worked as a Nurse Anesthetist for many years, a profession that requires a high degree of precision and manual dexterity. He underwent surgery on his cervical spine in 2006. Unfortunately, the surgery left him with significant weakness and loss of function in his right hand.

Without complete control of his hands to perform intricate medical procedures safely and effectively, he could no longer perform the tasks of a nurse anesthetist or one or more of the Essential Duties of Any Occupation.

Hartford initially approved his claim and paid benefits for more than two and a half years. Then his claim was terminated. Hartford based the denial on surveillance video, saying that activities seen on the videotape proved that he had the ability to perform one or more of the Essential Duties of Any Occupation.

We believe that Harford was less interested in the ability of our client to perform any essential duties as they were in minimizing its financial exposure.

We filed an aggressive appeal, attacking Hartford's overreliance on the surveillance footage, particularly where the medical records unequivocally supported the claim.

This is not the first time we have fought a long term disability insurance company's use of video surveillance.

The ability to perform the Essential Duties of Any Occupation for which he was suitable for based upon his age, education and experience requires the complete and full use of the hands.

Our appeal to the Hartford succeeded. Hartford reinstated all back benefits, and our client will continue to be paid on an ongoing basis.

If your long term disability insurance company has used surveillance videotapes to deny your claim, call our office to learn how we can help. This is one case where a picture is not worth a thousand words.

CHRONIC FATIGUE SYNDROME AND MET LIFE DOCTORS WHO DENY THAT ANYONE IS EVER DISABLED - FRANKEL & NEWFIELD WINS ERISA APPEAL

After representing long term disability insurance claimants for many years, we are familiar with many of the resources used by our insurance opponents. This includes the in-house attorneys, the outside counsel retained when things look grim, and the scores of medical doctors hired by the insurance companies who enjoy the benefits of a simplified practice.

Call us cynical, but for the same fee they earn doing one review of medical records, they would have to see numerous patients and their office staff would have to handle the accompanying paperwork. The review of medical records for a generous insurance giant is a great deal for any medical practice -- but a danger zone for any claimant.

So when our client, who suffers from a debilitating case of Chronic Fatigue Syndrome, was denied by Met Life, we were not surprised to see why. The doctors who were assigned to his file were a few of the regulars we know all too well. No one they see is ever disabled. Our client had exhausted the administrative process, and was in despair of ever receiving any of the insurance benefits he had so diligently paid for, for so many years.

We took his ERISA appeal to court and won.

The Court agreed with our client's claim that the Met Life decision was arbitrary and capricious, based on poor reviews of medical records and a failure to consider that he had qualified to receive Social Security Disability Insurance. The Court ordered Met Life to reconsider.

We aggressively attacked Met Life's doctor, piercing her credibility, citing case after case of paper medical reviews that were overturned by the courts because they were found to be inaccurate.

Our client received back benefits for more than three years, and is currently on claim.
If your disability claim has been denied because of a doctor's review of your medical records, it's a good chance that you've been denied for the sake of denial. You can fight back. Call our office to learn how we can help.

FRANKEL & NEWFIELD WINS PRUDENTIAL APPEAL FOR BREAST CANCER SURVIVOR WITH LUPUS AND THYROID DISORDER

A cancer survivor, suffering from also lupus, Hashimoto's Disease (a thyroid disorder) and obesity, contacted the disability insurance law firm Frankel & Newfield after Prudential denied her long term disability benefits. Our client was a Vice President with a worldwide financial services company, but even her high level executive skills were no match for the wall of denial constructed by Prudential.

Frankel & Newfield submitted a vigorous appeal that attacked Prudential on several fronts. Prudential hired MCMC to conduct the medical review. MCMC is one of Prudential's frequently used vendors, well known among the disability community for giving insurance companies what they pay so generously for - medical reviews that support the insurance company's policy of claim denial.

According to its own website, MCMC's objective is "to evaluate claims, review cases......that allow our clients to achieve positive outcomes through cost effective solutions." With the peer review services in particular, MCMC's stated goal is to provide assistance in "resolving disability claims questions in an effort to manage risk, control claim costs and increase productivity."

In other words, the insurance companies are their target market and the goal is to limit the insurance company's costs. This corporate mission is in complete opposition to the idea of the Independent Medical Review. MCMC's success in the insurance industry is arguably the result of its ability to provide medical reports that can be utilized to deny or terminate claims, thereby reducing the costs of managing disability benefits.

We also attacked Prudential's failure to provide the complete medical records for review. We see this happen many times: only a part of the medical records are provided to for review, and as a result, the medical professional does not get a total picture of the person's true disability. The law requires that a set of complete medical records be reviewed by a qualified medical professional.

The next prong of our attack concerned Prudential's' failure to provide an accurate job description, making it impossible to evaluate the material tasks and duties of her job. The duties of a high level executive are not the same as a mid-level manager or a clerk. To perform at this high a level in a global firm requires high level analytical abilities and physical stamina. Not only did Prudential use an outdated Dictionary of Occupational Titles, but they used a generic classification of our client as a Manager with light duty tasks.

After we submitted the appeal, Prudential decided that it needed a proper Independent Medical Exam (IME), which was conducted. Benefits were approved, and our client is now on claim.

If your disability claim has been denied and you are not able to work, it's a safe bet that the claim has not been evaluated properly and the insurance company is counting on your not fighting back. Call our office today and learn how we can help.

Federal Appeals Court Sends Clear Message to Disability Insurance Companies

The Appeals Court for the Fifth Circuit has issued a strong pro-claimant decision. What makes this decision significant is that the Court acknowledges that Hartford abused its discretion in denying benefits to the plaintiff and in addition to awarding benefits, will also grant payment of attorney's fees, making this an even better resolution to the insured's unfortunate situation.

The claimant, a practicing attorney, suffered from degenerative back disease and mental disorders for more than ten years. These problems interfere with his performance as an attorney, and in 2003, he applied for disability benefits. Hartford granted him a disability based on his mental disability, with two year benefit limit, but denied his claims of a physical disability. This is a common practice with Hartford (and other insurers) and one that Frankel & Newfield have dealt with in litigation. After being on claim for two years on the mental disability, he renewed his claim for his physical disability and was again denied. A long and arduous appeals process followed.
Three allegedly independent experts, all paid by Hartford to render opinions, found that he had not supported his physical limitations with objective medical evidence, despite a multitude of reports, studies, and a Functional Capacity Evaluation that indicated that he was not fit for sedentary work. In addition to ignoring a body of evidence, Hartford also neglected to recognize that the insured had qualified for Social Security Disability benefits.

After several appeals in the ERISA-governed administrative process, a lawsuit was brought in Federal court. The district court came down clearly on the insured's side, concluding there was an "overwhelming" body of objective medical evidence that he was physically disabled, and that Hartford "deliberately ignored overwhelming objective medical evidence" and saw fit to award him attorney's fees. The district court also observed that the Hartford was operating under a conflict of interest that could have had some effect on its decision. Hartford appealed, challenging both the conclusion that it had abused its discretion and the award of attorney's fees.

As attorneys representing plaintiffs in disability insurance cases, we are extremely pleased that the Federal Appeals Court agreed with the district court, and saw no reason to reverse its decisions regarding the granting of benefits to the insured and the award of attorney's fees. The Federal Appeals Court opinion has made it quite clear: Administrators who review cases do not have the right to arbitrarily discredit reliable evidence, and the district court has every right to award attorney's fees.

If you are facing a similarly difficult situation with your disability insurance company, call our office today to find out how we may be able to help you.

EMPLOYEES DON'T ALWAYS GET TO CHOOSE - BUT YOU CAN BE PREPARED

Unlike a privately owned Long Term Care Disability Insurance Policy, where you get to choose the policy, the selection of various additional riders or policy enhancements, and the company you purchase it from, most employees have to accept the disability insurance company that their employers have selected. Unless you are high up on the corporate ladder, or directly involved in the selection of the policy, there's little choice involved. What is purchased on your behalf is what you are left with.

However, that doesn't mean that you should not educate yourself about the insurance company and the policy. There are critically important terms that one should pay attention to which could impact a claim. Examples are where policies provide for a limited pay period for conditions related to depression or anxiety, while a growing number of policies have chosen to contain limited pay periods for self reported illnesses, chronic fatigue syndrome and other disorders. Claimants may be unaware of these limitations in benefit periods prior to filing a claim, and may only learn of this during the claim process - when the time for planning has already passed.

Online research will get you to any number of websites that report on insurance companies from the business side - their earnings reports, how they are rated by companies like Dun & Bradstreet, A.M. Best, or Moody's. It's a pretty safe bet that a company with slim earnings is going to be a bit more aggressive about protecting their reserves by delaying or denying claims than one that is sitting on a big pile of cash.

One of the first things we ask claimants when they engage Frankel & Newfield is if they have a copy of the original policy. It's a question that bears repeating because it could be critical to your situation. If you don't have the policy, contact your HR department or the agent to get a copy of the original policy. That policy is the contract between your employer and the insurance company, and the language in the contract changes from policy to policy. The policy that you received as an employee in the 1980s may not be the same as the one that you will receive today. Times change - and so do insurance policies.

You may not have any control about which insurance company your employer chooses to do business with. But you can prepare - by educating yourself about the company, making sure you have a policy, and reaching out for help with your claim. Frankel & Newfield works with claimants before, during and after the claims process - and we can help you too, at any stage of the claims process.

US SUPREME COURT DECISION ON ATTORNEY FEES UNDER ERISA A WIN FOR CLAIMANTS

If you have a long term disability insurance policy governed by ERISA, the United States Supreme Court has just handed down a decision in Hardt v. Reliance Standard that is very encouraging to policy owners and the attorneys who represent them.

The Supreme Court's decision is a major victory for ERISA disability insurance claimants and a warning to insurance companies that it may actually cost them money - more than just the cost of the policy benefits - if they wrongly deny or delay claims and a policyholder chooses to fight back.

There are a lot of moving parts in this decision. The key issues are:

A) whether or not ERISA provides a district court with the discretion to award reasonable attorney's fees only to the party who wins the decision and,

B) whether a party in a lawsuit governed by ERISA is entitled to attorneys fees if that party

1- persuades a district court that a violation of ERISA has taken place,
2 - wins a court-ordered decision that requires a benefit decision to be reviewed, and
3 - wins the benefits sought following the review.

The decision in Hardt v. Reliance Standard holds that a party that seeks to recover attorney's fees is not required to be victorious in all parts of a lawsuit for a court to decide to award attorney fees.

Ms. Hardt had to stop working as a result of medical problems and filed a claim for disability insurance benefits under her employer's long-term disability plan. When she exhausted the administrative remedies, Mrs. Hardt brought a lawsuit against Reliance, alleging that it had wrongfully denied her claim. The District Court found that the carrier had acted on incomplete medical information and that the denial was not based on substantial evidence. The Court also concluded that Reliance would get the chance to address the medical review, giving Reliance 30 days to consider the evidence and make a decision. Reliance reviewed the file and awarded Hardt benefits.

Hardt filed a motion to recover attorney's fees. The District Court agreed with Hardt, and Reliance filed an appeal. The Fourth Circuit Federal Court disagreed, vacating the award, arguing that Hardt had failed to establish that she was a "prevailing party," which is defined in a landmark case that a fee claimant is a "prevailing party" only if they have won an enforceable judgment or a court -ordered consent decree.

Common sense would dictate that someone who wins back their benefits from an insurance company has won the case, and that should be enough to be considered the "prevailing party," but the letter of the law is very specific. The Federal Court decision was appealed to the United States Supreme Court, the highest court in the nation.

The US Supreme Court agreed that a person seeking attorney's fees need not be a "prevailing party" in cases governed by ERISA. The term itself does not appear in one section of the legal statute that created ERISA, nor does anything else in the section indicate that only the "prevailing party" should be awarded legal fees. To the contrary, the statute expressly gives district courts the discretion to award either party attorneys fees. In direct contrast, another portion of the statute is very clear about awarding attorney fees in cases where there is an issue of employer contributions to multi-employer plans.

If you have any questions about Hardt v. Reliance Standard and what this decision may mean for your situation, call our office today. This is one battle you do not have to take on alone.