Disability Insurance Lawyer Blog

ProHealth.com Features Article from Frankel & Newfield - What You Need to Know to Avoid the Disability Claim "Brush Off"

Many of our clients suffer from Fibromyalgia, Chronic Fatigue Syndrome (CFS) and similar illnesses that long term disability insurance companies do not consider real sicknesses. We were pleased to share our experience representing CFS and Fibromyalgia claimants and provide information on filing disability insurance claims to subscribers of www.ProHealth.com, a website that offers information, resources and products for individuals with chronic illnesses.

Key points in the article:

• Find the original policy.

• Speak with your treating physician about filing a claim

• Be aware that the information you provide in all forms and documents
may be used to build a case against your claim.

• Document and record every interaction with the insurance company.

• Be wary of independent medical exams (IMEs) and be careful of
functional capacity evaluations (FCEs).

Click here to read the article and visit Pro Health's extensive website.

If you have a chronic illness and are concerned about filing a claim, call our office today to learn how we can help.

PRUDENTIAL DENIES DISABILITY CLAIM WITHOUT A REAL MEDICAL EXAM

Late night television commercials sell life insurance, boasting that no medical exam is required. How about a disability insurance company that doesn't need a medical exam - in this case, to deny a claim? Maybe these companies need to get together....

Our client is a CPA whose conditions, which include Fibromyalgia, Chronic Fatigue Syndrome, chronic sinusitis, hypothyroidism, depression and anxiety, ovarian dysfunction, endometriosis, torn superior labrum, degenerative disc disease, migraine headaches, failed back surgery syndrome, facet arthritis, foraminal narrowing, and chronic pain, were too debilitating for her to perform in the duties of her job. Key issues driving this matter -lack of a proper medical review and a complete failure to accurately assess the tasks and duties of her occupation.

The doctor who did the peer review works for a company whose sole function is to review medical claims on behalf of insurance companies. Their reviews are supposed to be independent, but the company's only clients are insurance companies. The physician was not well versed in any areas of the client's numerous disabilities. Most outrageously, the doctor never examined the client in person, even though the policy gives the right for the insurance to do so.

Prudential relied on a generic classification of the client's job as a desk job and totally ignored the strenuous cognitive demands of a CPA. We have seen this same tactic time and time again - an occupational review based on an outdated document - the DOT (Dictionary of Occupational Titles). The DOT is completely useless for a service-based economy, but the insurance companies continue to use it, as it works to their benefit in claim disputes.

Prudential failed to afford the client a full and fair review of her claim, failing to consider her credible subjective complaints, selectively reviewing the medical records, failing to conduct an appropriate vocational analysis, and failing to act as a neutral fiduciary. Rather, Prudential acted as an interested party influenced by its financial stake in the claim.

We fought back, with a vigorous appeal denouncing Prudential's irresponsible medical review, occupational review and failure to act as a disinterested party. We won - and now our client is able to focus on taking care of her health challenges and not fighting with a massive insurance company that was determined to deny her claim.

If you are a professional who has become disabled, do not accept the denial based on an inaccurate evaluation of the tasks and duties of your career. Call our office today and learn how we can help you fight back.

Insurer Unable to Apply Mental and Nervous Policy Limitation

Score one for the disability insurance claimant, as a Federal Judge recently determined that it was improper for Standard Insurance Company to seek to apply a limited benefit period to a claim for benefits resulting from a mixed impairment. The claimant, a physician with a long history of migraine headaches and depression, was paid benefits under his ERISA group insurance policy, but the claim was terminated at the 24 month mark, on the basis of the mental and nervous limitation.

The Court determined that because the migraine headaches were in and of themselves disabling, any effort to apply the limited benefit period was improper. The Court rejected a number of interesting arguments, including one that the opinions of the treating doctors were entitled to less weight because they were prepare specifically to support a finding of disability (in contrast with the typical insurer provided peer review reports?).

This decision could be of great benefit to the long term disability claimant community, as we often see insurance companies handling long term disability insurance claims seeking to invoke the limited benefit period under a mental and nervous limitation. If your disability involves both mental or nervous conditions as well as physical limitations, we can help you with your claim.

CIGNA Long Term Disability Claim Denied, Frankel & Newfield Win Benefits Back

How claim adjusters made the decision to deny disability never fails to surprise and shock us. This one is so outrageous that it defies understanding. Our client is a 52-year-old management consultant who suffers from early onset dementia, early onset Alzheimer's, degenerative disc disease, osteoarthritis, obesity, hypothyroidism, hypertension, hyperlipidemia, vitamin D deficiency, fatigue, fibromyalgia, sleep apnea, migraine headaches, depression, anxiety, TMJ disorder, and plantar fasciitis.

His long term disability insurance carrier, CIGNA, denied his claim for benefits in April 2010. We appealed the decision based on the following:

Our client's work was rapid, detail rich, and time critical, with significant amounts of human interaction in a stress-filled, fast-paced, cognitively demanding work environment. Almost every hour presented new problems and dynamics that required continuous re-thinking, re-assessment, re-grouping, and re-planning. CIGNA never did a proper vocational analysis and relied only on the physical aspects of the job. Management consultants and steel workers do not have the same physical challenges, although both require strong mental capacity and the ability to make quick and critical decisions.

CIGNA completely and utterly failed to take all of the client's physical AND mental disabilities into consideration. In another area of the law, that would be deemed bad faith.

When the initial review of records was done by CIGNA's medical personnel, not all records were available and the medical personnel were told to make a decision without the missing records. That's not just sloppy workplace behavior - that's intent to harm.

CIGNA relied on the DOT to determine that the client was not disabled. The DOT is an overly generalized and largely outdated database that does not accurately describe occupations as they exist in today's labor market. The DOT was first published in 1938 with an emphasis on blue-collar jobs. It is no longer relevant to information and services professions, yet CIGNA stilled relies upon it.

CIGNA failed to take the treating doctors' opinions into consideration and instead relied on paid medical consultants who had never even met or spoken with our client.

CIGNA never had our client examined in person and instead relied on three flawed and biased reviews by unqualified, in-house medical personnel and the reports of two paid consultant who did a review of records only. These consultants were contracted through IntraCorp, to do an "independent" paper review. IntraCorp, at the time our client's review was done, was a sister company of CIGNA. In recent cases, CIGNA has been chastised by the courts for using Intracorp to perform peer reviews.

The Courts have said "that the point of having a third party medical provider is for it to make independent medical judgments. If, however, it is nothing more than a captured sister company of LINA, that information could be indicative of bias in the review process." The paper reviewing doctors used in our client's claim denial have produced dozens of reports in favor of insurance companies. In fact, in more than 30 cases, these paper reviewing doctors determined that each and every claimant was not disabled. Ample proof of this was submitted with the appeal.

CIGNA's failure to conduct a proper vocational assessment, in combination with its failure to perform a proper medical review with respect to the specific duties of the client's occupation, provided undeniable evidence of CIGNA's arbitrary and capricious conduct and its failure to provide the client with a full and fair review of his claim.

Throughout the review process, CIGNA relied on selective portions of the medical records, blindly embraced the flawed findings of its unqualified in-house nurse consultants, and failed to appropriately evaluate the occupational requirements, all of which resulted in an erroneous and unfounded denial of his claim for benefits.

We submitted an appeal with unwavering support from the clients' treating physicians', a detailed job description and analysis as to why the client was disabled from his own occupation. CIGNA reversed their decision and determined that the client was disabled from his own occupation as a management consultant. He is now being paid.

Moral of the story - if your disability insurance company denies your claim, you can fight back, and you don't have to fight back alone. Call our office today at 1-877-583-2524 to learn more.

EPSILON DATA BREACH IMPACT ON DISABILITY INSURANCE CLAIMS

The Epsilon data breach, which took place during the last week of March and was announced over the weekend, has exposed the names and emails of millions of customers of brand-name companies, including Target, Kroger, TiVo, US Bank, JPMorgan Chase, Capital One, Citi, Home Shopping Network, 1-800-FLOWERS, Ameriprise Financial, LL Bean Visa Card, McKinsey & Company, Ritz-Carlton Rewards, Marriott Rewards, New York & Company, Brookstone, Walgreens, The College Board, Disney Destinations, and Best Buy, to name just a few.

Epsilon is the world's largest provider of permission-based email marketing. More than 40 billion emails are sent yearly for 2,500 brands. If you've ever sent an email, it's likely they have you in their system - and likely that you will start receiving more phishing emails than ever before. You might receive a message from a store or an insurance company with your name, with all the right logos, and think that it's legitimate. Just opening the email can expose your system to a dangerous computer virus.

If you are in the process of filing a claim or have a claim filed with a disability insurance carrier, you need to be extra vigilant. Insurance companies share data with third parties and there may be affiliated relationships that are not widely known. Caution is the best tactic. If you receive a request for information from a new email address, call the claims adjuster to verify that the request came from their office.

Check the email address - if it is slightly different or ends in something other than .com, particularly an international domain like .uk, it is likely to be a phishing email. Most phishing campaigns originate outside of the U.S. Look for spelling errors in the email address, URL or any email that appears to be urgent.

If you have questions, call us at 877-LTD-CLAIM (1-877-583-2524).

AETNA CLAIM DECISION LACKS SUBSTANTIAL EVIDENCE

A Federal Judge has demonstrated that despite a favorable standard of review for an insurance company, a claim decision must be supported by substantial evidence, or it will be reversed. Aetna reached a claim determination on the purported basis of medical reviews performed by its in house physician and an outside physician consultant, neither of whom examined or evaluated the claimant.

The Court carefully considered the substance of the reports relied upon by Aetna, and determined that these reports lacked substantial evidence, due to the selective inclusion of information, and the failure to consider support for the impairment from the claimant's treating medical providers, coupled with the mischaracterization of the medical findings by another hired physician.

The Court noted the value of a physical examination to a reliable assessment of a claimant's disability. The Court chastised Aetna for searching for a reason to deny benefits, where Aetna blindly accepted the paper review conclusions over the opinions of treating physicians, without meaningful explanations as to why.

Unfortunately, this decision is more the exception than the rule, and all too often, insurers are permitted to engage in like conduct, without meaningful scrutiny by the Courts. Often, the courts determine that it was appropriate for an insurer to rely upon these "independent" physicians, or even to rely upon in house doctors who do not even practice medicine on patients, fail to conduct an examination of the claimant and demand objective evidence, even where the policy does not contain such a requirement.