Articles Posted in Long Term Disability Claims

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Chicago-225x300Attorney, Keith R. Siskind of the Law Offices of Steinhardt, Siskind and Associates, LLC, attended the American Bar Association ERISA Litigation Seminar held in Chicago from June 7th through June 9th, 2017.   This seminar explored a variety of topics associated with claims under the Employment Retirement Income Security Act (ERISA).  The seminar was formulated to provide experienced ERISA practicing attorneys with additional information and resources for filing, appealing and litigating ERISA claims, particularly claims for long term disability benefits under an employer sponsored group insurance plan.

When pursuing a claim for short term or long term disability insurance benefits under a group insurance plan it is fundamentally important to provide the insurance carrier, or claims administrator, with sufficient medical information to document a claimant’s inability to engage in the material duties of either their own occupation, or any occupation, depending upon the definition of disability applicable at the time.  Most group disability insurance plans limit a claimant’s recovery of  disability benefits to 24 months for an inability to perform the claimant’s own occupation.  The insurance carrier will conduct a review to determine whether the claimant meets a stricter definition of “any occupation” after the payment of 24 months of benefits. (In some plans the period may be 12 or 36 months before transition.  There are also plans that will provide solely for “own occupation” benefits – Make sure you have a copy of the group plan and check the policy language – ask your employer to provide you with a copy of the plan if you do not have one).  Group plans may also include other limits on benefits for a mental health condition, or self reported symptoms.

One of the most critical aspects of submitting medical information is to provide medical evidence of functional restrictions and limitations that demonstrate an inability to work due to a physical, cognitive or mental health condition.  An experienced ERISA attorney can review the claim and assist you with obtaining the necessary medical information to support your claim.  This may include securing a Disability Work Assessment, Functional Capacity Evaluation,  Psychological Evaluation, Vocational Evaluation, or other testing relevant to a claimant’s particular medical condition and the nature of the claimant’s occupational duties.  It is also important to obtain and review the insurance carrier’s administrative record and provide medical documentation to refute the opinions of peer review physicians retained by the insurance carrier.

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Attorney, Keith R. Siskind of the Law Offices of Steinhardt, Siskind and Associates, LLC, attended the American Conference Institute seminar on Litigating Disability Insurance Claims held in Boston on September 14 and 15, 2016.  The seminar addressed multiple issues associated with disability insurance claims.  These issues include the applicability of ERISA, remedies, discovery, and contractual limitations.  Cases often turn on the applicable standard of review to be applied by the court when resolving disability claims.  The Department of Labor has proposed new Federal Regulations that will help create a more even playing field for a claimant by providing claimants with an opportunity to respond to medical reviews obtained by the insurance carrier before a final decision is issued on appeal and requiring strict compliance from insurance carriers.  It is hopeful that these new regulations will become effective shortly.

More importantly, this seminar reinforced how critical it is for claimants to have experienced legal counsel when pursuing disability insurance claims.  The process is cumbersome.  Insurance companies increasingly seek more information to document a claimant’s disability.  A claimant needs an attorney to help sort through the complex medical and other documentation that is required to get a claim approved.  An attorney can assist with reviewing the claim, obtaining applicable records, securing appropriate evaluations and challenging a denied claim by the insurance company.

When a claimant becomes disabled and is unable to work, it is often a  stressful time both emotionally and financially for the claimant and their families.  Not only does the claimant have to deal with their medical condition and the financial loss of income, but also the minutiae of information that the insurance company seeks to document a disability.  Do not try to pursue such a claim without experienced legal counsel to navigate you through this process.  It can be overwhelming.  You need the support that an experienced disability attorney can provide.

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agreement-signing-251732-m-2In the 2012 case of Garcia v. The Hartford, the surviving spouse of Jose Garcia, Elvira Garcia, sued the insurance company The Hartford for a violation of ERISA. The decedent had participated in his employer’s long-term disability plan. The plan was insured and administered by The Hartford and was governed by ERISA.

The purpose of the plan was to give policyholders protection against loss of income in the event of disability. The covered employees were to receive long-term disability benefits—a portion of monthly income—if they were so disabled they couldn’t work. The payments would end when the disabled employee could come back to work. By the policy terms, The Hartford had the authority to interpret all terms and provisions of the plan.

In 2004, the decedent had a heart attack, and the insurer approved his long-term disability benefits claim. However, the insurer told him that the payments would be reduced by other benefits, such as Social Security Disability Insurance (SSDI). At the time of the approval, he wasn’t receiving SSDI, but the insurer directed him to apply. Subsequently, he signed a reimbursement agreement in which the insurer claimed he had applied for other benefits. Continue reading →

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video-camera-1412649-m-2If you make a claim for disability to an insurer, you should be aware that some insurers conduct video surveillance to assess whether you are being truthful about your injuries or disabilities. They also sometimes check on your social media updates. In a recent case a plaintiff sued Life Insurance Company of North America (LINA) for cancelling his long-term disability benefits. LINA counterclaimed against him to recover an alleged over-payment of $57,527.60 in long term disability benefits. Both filed motions for summary judgment in federal district court.

For three years the plaintiff had worked as a sales rep for an electronics business. The business offered employees a long-term disability plan governed by ERISA. The claim administrator was LINA, which had to administer benefits claims as a fiduciary in accordance with all relevant instruments.

In 2001, the plaintiff hurt himself while lifting boxes and computer parts at work. He stopped working in 2002 because of cervical disc disease, migraines, and facet arthropathy. A few months later his claim for long term disability benefits was approved with monthly benefits of $5225.00. Continue reading →

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chest-xray-262068-mThe short answer is that it depends on the plan language. However, it is common for plans to include a provision whereby the benefits they owe a claimant will be offset by any Social Security benefits they receive. A Maryland attorney familiar with both private and government disability claims can look at the written policy and help you determine what benefits are available to you.

In a recent case dealing with this issue, a plaintiff filed suit against US Cotton LLC Long Term Disability Plan and related defendants claiming, among other things, they wrongfully denied him benefits. Two defendants filed a motion for judgment on the pleadings. A third entity related to the defendants moved to dismiss the case.

The case arose when the plaintiff was diagnosed with chronic obstructive pulmonary disorder (COPD). It caused him to have breathing difficulties. His doctor told him to maintain all forms of insurance. He purchased a private long-term disability policy so that his family was provided for in the event he couldn’t work. The next year, he also purchased long-term disability insurance through a new employer (US Cotton). Continue reading →

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parchment-1-350377-mAs we’ve mentioned in other posts, the language of your long term disability plan is controlling in Maryland. An insurer can give itself complete discretion about whether to award benefits. This is one reason it is important to look at your plan documents when you enroll in a plan, and retain an attorney as soon as you become aware that the insurer does not want to pay you benefits. An experienced Maryland attorney can look at your plan language to see whether you can challenge an insurer’s adverse decision.

In a 2013 case dealing with interpretation of a disability benefits plan, the court considered whether an employer’s short-term and long-term disability benefits plans left a plan administrator with discretionary decision-making authority. The issue in the case turned on whether an employer’s group insurance plan required “objective” evidence of disability for an employee to qualify.

The case arose when a senior clinical marketing manager for a medical diagnostics company began to experience fatigue, sleep apnea, hypotension, and weight loss. The medical diagnostics company had a group insurance contract with Prudential, which administered both short and long-term disability benefits plans. The manager participated in both plans, which provided for disability benefits if she wasn’t able to perform the material duties of her regular job because of sickness or injury. Continue reading →

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People attending a Congress
On December 4, 2013 attorney Keith R. Siskind attended the 26th annual ERISA Litigation Conference in New York.  The conference provides an opportunity to network with other professionals and obtain updated information on recent cases and issues involving long term disability insurance benefit claims under the Employment Retirement Income Security Act.

The process of leveling the playing field against long term disability insurance companies continues, as some states, such as Maryland, have adopted regulations prohibiting the use of discretionary review provisions in disability insurance policies. In Maryland the policy must have been issued after October 1, 2011 http://law.justia.com/codes/maryland/2013/article-gin/section-12-211/  Such litigation will now be subject to an independent decision by a  Judge to determine disability in lieu of an abuse of discretion review to determine whether a disability insurance company’s denial was reasonable.

Furthermore, there is recent case law examining the language of a long term disability plan and the type of evidence that a long term disability claimant must submit to meet the definition of disability under a plan.  The court requires that the plan language must be specific and spell out whether objective proof of a medical condition is required. (Cosey v. Prudential Ins. Co. of Am., 2013 BL 312282, 4th Cir., No. 12-2360, 11/12/13) http://www.boomerisablog.com/files/2013/11/Cosey-v-The-Prudential-Insurance-Company.pdf

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1409595_gavel_5A potential client will often call seeking legal assistance regarding their denial of long term disability insurance benefits by an insurance carrier.  After further inquiry it is determined that the client was denied benefits some time ago and submitted their own appeal to the insurance company which may have consisted of a letter from the client explaining their symptoms and a letter from the client’s doctor with a bold statement indicating that the client is totally disabled from work.  Such evidence is generally insufficient in the eyes of the insurance company which then issues another denial letter. This becomes the final denial exhausting all of the client’s administrative remedies.  The alternative at this point is to file a lawsuit but the chance for success may be limited since the administrative record may not have enough evidence to document functional limitations.

This example is exactly the reason why an individual who is denied disability benefits should contact an  experienced disability attorney.  Under the Employment Retirement Income Security Act (ERISA) an Employer’s disability plan may limit the evidence of disability to the documentation in the administrative record.  Consequently it is imperative to submit appropriate medical and vocational evidence to document an individual’s functional limitations and inability to perform either their own or any occupation depending upon the definition of disability in the plan.  The insurance carrier will use its resources to obtain a peer review from a physician or an employability analysis from a vocational rehabilitation counselor to dispute the claim for benefits.  An experienced disability attorney with knowledge of the administrative appeal process can help secure the evidence needed to advocate for your benefits.  An appeal that is submitted without appropriate supporting evidence may prejudice your claim and diminish your chances of getting the benefits that you deserve.

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