Disability Insurance Lawyer Blog

ProHealth.com Invites Questions on Disability Insurance Claims

Frankel & Newfield has published several articles on ProHealth.com, which features articles and information for patients who take an active role in managing their health. The site is particularly focused on people suffering from Fibromyalgia, Chronic Fatigue Syndrome and other chronic illnesses. In our fourth article, we invite visitors to the site to ask about issues they face concerning their Long Term Disability Insurance policies.

We also review some of the basics that claimants need to know, including when claims need to be filed, the importance of the treating physician to a successful claim, and what options exist when claims are denied, delayed, or terminated.

If you have questions about your long term disability insurance policy, call our office today to learn how we can help you. Call 800-LTD-CLAIM (877-583-2524).

Long Term Disability Insurance - What Legal Rights Do You Have?

When you sign up for LTD insurance or purchase private LTD insurance on your own, you are embarking on a legal and contractual relationship. Unfortunately, the policies are complex, even by legal document standards, and are next to impossible for the layperson to easily understand. To make matters worse, policies that are part of an employee benefits package are typically governed by ERISA, the law created to protect employees from unscrupulous employers that has been twisted into a defense wall by insurance company lawyers.

Do you have any rights when it comes to disability insurance policies?

In a word, yes. But there are some real limitations that you need to know about.

For Long Term Disability Insurance policies that are from your employer, you do not have the opportunity to immediately take your case to court or ever be heard before a jury of your peers. Instead, you are compelled to undertake an administrative appeals process - essentially asking the insurer who denied or terminated your claim to alter their position. In litigation of these types of claims, as a general proposition, the only materials that may be submitted to the Court are those that are in your insurance company file, known as the administrative record. So if your primary physician fails to submit an up to date report that has critical information about your condition, you may be precluded from having the Court understand or consider your most recent medical concerns.

Unlike nearly any other dispute in any other area of the law, there are no 'damages' available to pursue in a disability insurance claim. There is no penalty to the insurance company for the weeks, months, even years of anguish that you are put through by their denial or wrongful termination of your claim. If you have suffered irreparable financial harm from the denial that is later reversed, including having to file bankruptcy or losing your home, there is no claim in a disability insurance case that will receive anything from the disability insurance company except the benefits that were supposed to be paid to you.

However, hope may become available, as the United States Supreme Court recently issued a decision that may lay the groundwork to pursue these types of claims, under a "surcharge" theory.

Expert witnesses are not typically part of the disability insurance litigation process. In fact, most often, there are no witnesses at all. Your boss who knows how hard you worked when you were well can't testify on your behalf about the awful changes that have happened to you as a result of your disease or injury. Community members who would defend your character and work ethic are not allowed to speak on your behalf. It has to be in the administrative record.

Thus, in developing an appeal to a denied or terminated claim, it is imperative to include these types of materials, to buttress your credibility and have the record reflect the issues that you will seek to argue to a Court.

We'll examine the bill of rights for privately owned disability insurance policy owners in our next post.

Court Finds Sedgwick Claim Determination to be Arbitrary and Capricious

A Federal Judge in New Jersey has determined that a decision to terminate long term disability insurance benefits to a claimant suffering from lupus, rheumatoid arthritis and other conditions was arbitrary and capricious. The Court undertook an analysis that accounted for a number of case specific factors, taking guidance from the United States Supreme Court's holding in Met Life v. Glenn. Sedgwick is a third party administrator who does not insure the benefits, but rather handles claims for employers as the administrator.

The Court noted that Sedgwick's failure to comply with the ERISA regulations requiring appropriate notification of what is necessary to perfect a claim, along with the failure to consider all relevant medical conditions, and the failure to consider the SSDI award were factors weighing in favor of a finding of arbitrary and capricious conduct. The Court also found that Sedgwick's requirements of proof not contained in the policy, along with a changing of claim position without new information further supported a finding of arbitrary and capricious conduct.

On the other hand, the Court did not credit the use of repeat offender paper reviewing physicians as having any weight, noting that their was no evidence of bias presented to support the argument. However, by correctly weighing the totality of circumstances, the Court held that the decision to terminate the claim was improper, and ordered a portion of the back benefits to be paid, while remanding the claim back for further consideration.

Connor v. Sedgwick Claims Management Services

Court Finds CIGNA Arbitrary, Applied Wrong Standard of Disability

A recent decision from the Federal Court in Pennsylvania has chastised CIGNA's claim handling conduct and awarded back benefits to an insured whose claim was terminated by CIGNA based upon its effort to apply the wrong standard of disability. CIGNA terminated the claim on the purported basis that the claimant was able to work in some occupation, despite the fact that her claim was in the own occupation stage. In litigation, CIGNA sought to argue that this was a typographical error, and that it actually applied the own occupation standard.

The Court methodically picked apart the arguments, and demonstrated how CIGNA wrongfully applied the any occupation definition. The Court also rejected CIGNA's argument that evidence supported its claim decision under whatever standard was applied, factually demonstrating why CIGNA's argument lacked merit. The Court held that "any action taken by a plan administrator inconsistent with the terms of unambiguous policy language is arbitrary."

This strong decision serves to highlight how insurers often will apply erroneous standards, and will attempt in litigation to craft arguments to fix the holes in the logic of the underlying claim handling. Fortunately, this Judge appreciated the issues, and did not permit CIGNA to "mend the hole".

Loomis v. Life Ins Co. of N. Amer. (CIGNA)

SUN LIFE LAUNCHES MALPRACTICE INSURANCE RIDER FOR DISABILITY POLICIES WITH DOCTORS & DENTISTS IN MIND

Here's some good news and some bad news about disability insurance for physicians.

The good news is this: a smart person at The Employee Benefits Group division of Sun Life Financial has figured out a new benefit to offer their doctor, dentist and medical practice policyholders of disability insurance policies - a Malpractice Insurance Reimbursement rider. The physicians and dentists who are out on disability will receive a reimbursement of their malpractice insurance premiums while they are out of work.

It's a smart idea, because medical malpractice premiums are steep, and they must continue to be paid while the doctors and dentists are out on disability. There is a limit of the amount - $25,000 - and the time - 12 months - which is also smart - it caps Sun Life's exposure. It s an innovative product and one that doctors and dentists are likely to embrace.

So what's the bad news?

Sun Life is one of many major disability insurance companies that we frequently find ourselves battling in cases on behalf of physicians and dentists whose disability insurance claims have been denied or are being delayed. So once again we find ourselves forced to take a cynical position.

Reimbursing your Malpractice Insurance premiums sounds like a great idea - but is that before or after the claim is delayed or denied? And if the claim is initially denied and then won on appeal, will you still be entitled to that nice $25,000 reimbursement to pay your medical malpractice premiums, or will that become another arm of a legal hydra you have to tame?

When making decisions on purchasing a long term disability insurance policy, we are less concerned with the add-ons than we are with the genuine thing: an insurance company that stays with the concept that when you are disabled enough to have to stop practicing medicine or dentistry, the insurance company that sold you a policy will pay the benefits, as promised and as agreed to in your contract.

If you are a physician or dentist and your disability insurance company has denied your claim or is delaying it, give our office a call. We can help.

Hartford Study Finds that Most American Workers Do Not Have Disability Insurance

Regardless of the challenges presented by disability insurance companies to claimants, disability insurance is something that everyone who works for a living should have. During the course of a working life, the likelihood of becoming disabled is higher than the likelihood of dying.

A recent study related by The Hartford, a major disability insurance company, shows a dramatic decline in the number of Americans who lack either short-term or long term disability insurance. Exactly 49% of workers carry short-term disability insurance, while fewer (44%) possess long-term disability insurance, The Hartford's research found. The decline is likely a result of a tough economy which has forced both employers and their employees to cut costs.

The majority of American workers lack either short-term or long-term disability insurance, and just 25% of workers completely understand the offerings, according to a new study. Only 25% of workers completely understand disability insurance.

The problem is this: 2 million Americans a year become disabled through an illness or an injury, and disability insurance is supposed to serve as a financial safety net. That's why our disability insurance legal practice is so busy - the safety net for the disabled worker is too valuable to allow it to be denied or delayed without a hard fight.

If you have disability insurance but you don't understand it and are considering filing a claim, or if you have been denied disability benefits or your claim is being delayed, call our office to learn how we can help protect your financial safety net.

LONG TERM DISABILITY INSURANCE BENEFITS CLAIM DENIED BY MET LIFE, SUCCESSFULLY APPEALED BY FRANKEL & NEWFIELD DISABILITY LAWYERS

Our client held a highly demanding position in senior management for a large international company. She filed a claim for long term disability insurance benefits with MetLife, suffering from severe depression, anxiety and panic disorder, combined with physical disabilities, including Fibromyalgia and degenerative osteoarthritis, accompanied by pain, fatigue and weakness.

MetLife accepted the claim and paid benefits for six months, then abruptly terminated her long term disability insurance claim. There had been no improvement in her condition, but there had been a paper review of her file by an on-staff nurse.

Frankel & Newfield was retained to file an appeal of the termination of her disability claim. We knew that the denial had been made with little or no recognition of the physical and mental challenges of her occupation. We also know that the paper review by a nurse was inaccurate.

We worked closely with our client and her treating psychiatrist on developing the medical support regarding her mental and cognitive limitations. We also worked with her other medical providers to develop a strong case based on the physical conditions that made it impossible for her to work. Finally, we proved that the combined effect of our client's mental and physical impairments resulted in her inability to work.

Frankel & Newfield succeeded in having MetLife overturned their decision, and our client continues to receive long term disability insurance benefits.

If you were receiving disability insurance benefits and suddenly your claim was terminated because of a paper review, call our office to learn how we can help put your claim back on track. This is one fight you don't need to handle alone.

When the Doctor is the Patient - Frankel & Newfield Article in American Chiropractic Association News

We are pleased to share an article recently published in ACA NEWS, published by the American Chiropractic Association, the largest professional association in the US representing doctors of Chiropractic. The article explores the concerns and hurdles faced by chiropractors when filing a long-term disability insurance claim, and why filing an LTD claim for yourself is a completely different experience than filing health insurance forms for patients. Justin Frankel and Jason Newfield advise claimants that paying disability claims is expensive to the insurance companies, and disability insurance companies have a vested interest in minimizing their exposure.

If you are a chiropractor and have a disability claim that has been denied or seems to have stalled for no apparent reason, or if you are thinking about filing a disability claim, call our office to learn how we can help.

To read the article, click here: ACA News - When the Doctor is the Patient - June 2011.pdf