Disability Benefit Claims Law Blog : Disability Benefits Lawyer & Attorney : Dell & Schaefer : Disability Insurance Claims Law Blog

Plaintiff Robert DeMoss appeals from an order of the district court in favor of the defendant, Matrix Absence Management, Inc. (Matrix).

As an employee of LSI Logic Corporation, Robert DeMoss was a participant in his employer's LTD group insurance policy administered by Matrix. On May 10, 2002 Matrix found DeMoss eligible for LTD benefits based on a mental, emotional, or nervous illness. However, Matrix denied LTD benefits due to diabetes complications, cardiac neuropathy, and eye problems. After receiving notice of the decision, DeMoss requested administrative review of the decision, but Matrix never responded.

District Court review

More than seven years later, in December 2010, DeMoss sought review in district court asking the court to award him LTD benefits based on physical disability or to order Matrix to conduct further evidentiary review. The District court ordered Matrix to determine whether DeMoss was eligible for LTD benefits because of his claimed physical disabilities.

The court's order specifically provided that:

Upon remand to the administrator, Defendant must provide Plaintiff a full and fair review. If Defendant denies Plaintiff's request for physical long-term disability benefits, Defendant must set forth its reasons and rationale, and allow Plaintiff to submit additional evidence supporting his claim for physical disability benefits. After Defendant has provided its rationale and Plaintiff has submitted additional evidence, if any, Defendant should evaluate Plaintiff's claim as it would an appeal from an initial denial of benefits. Matrix should render its decision within 120 days from the date of this Order and the decision shall be final for purposed of exhausting remedies.

Matrix denies DeMoss's claim for LTD benefits for the second time.

The 120-day review period ordered by the court expired on October 8, 2009. By letter dated June 30, 2009 which DeMoss received July 6, Matrix denied DeMoss's claim for LTD benefits based on physical disability.

DeMoss did not request administrative review or submit additional evidence during the duration of the review period. Instead, on August 20, DeMoss filed a motion with the court to extend the time to seek administrative review explaining that he was not prepared to complete. The court denied the motion on the grounds that it did not have authority to change the plan documents.

DeMoss argues that ERISA regulations required that he have 180 days in which to request an administrative review instead of the court ordered 120-period.

According to ERISA, which governed DeMoss's group LTD policy, a claimant has 180-days in which to request an administrative review of a claim denial. Nevertheless, the district court denied DeMoss's motion for further review by Matrix. The court reasoned that because DeMoss had failed to seek review of the adverse benefit determination during the court ordered review period, DeMoss was not entitled to further review.

Court finds DeMoss failed to request a review of Matrix's benefit-denial decision or to provide Matrix with additional and/or updated medical evidence during the court-ordered 120-day review period.

In its order in favor of Matrix, the district court held that DeMoss had failed to exhaust his administrative remedies and that no exception to the exhaustion requirement applied.

DeMoss subsequently appealed to the United States Court of Appeals for the 10th Circuit arguing that:

1. the district court was wrong in denying his request for an extension of time to seek administrative review;
2. the district court was wrong to refuse his request for an order allowing him to exhaust his administrative remedies; and
3. if he had failed to exhaust his remedies, such failure should be excused because further efforts on his parts would have proven useless.

The Court of Appeals refused to accept any of DeMoss's arguments. Instead, it agreed with the district court in saying that DeMoss had failed, in the initial appeal of the adverse benefit determination, to argue that Matrix's plan did not comply with federal regulations. The court therefore reasoned that DeMoss could no longer raise such an argument. Moreover, the court concluded that DeMoss had failed to convince it that his failure to exhaust his remedies should be excused. As such, the court found in favor of Matrix.

About the author: Gregory Michael Dell is an attorney and managing partner of the disability income division of Attorneys Dell & Schaefer. Mr. Dell and his team of lawyers have assisted thousands of long-term disability claimants with their claims against every major disability insurance company. Request a free legal consultation here or call 800-698-9162.

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Disability Blog & Cases:
Oregon Judge orders Standard Insurance Company to pay disability insurance benefits beyond the 24 month mental disorder limitation

In James F. Kitterman Vs Standard Insurance Company and Standard Select Trust Insurance Plans, the plaintiff, through his Oregon disability attorney, brought an ERISA action against the Standard Insurance Company (Standard) seeking to recover long term disability insurance benefits wrongfully denied under the terms of a group insurance plan (the Plan) issued by The Standard Insurance Company. This case is a victory for disability claimants and addresses an issue that is very common among thousands of claimants seeking disability benefits.

Disability Blog & Cases:
Bridgestone employee sues Liberty Life Assurance Company of Boston for long term disability benefits

Sandra Cotton-Lyons filed a lawsuit against Liberty Life Assurance Company of Boston (Liberty Mutual), Administrator of the Bridgestone Americas, Inc. Long Term Disability Plan in the United States District Court for the Eastern District of North Carolina. As an employee of Bridgestone Americas, Inc. (Bridgestone Firestone), Cotton-Lyons, a resident of Rocky Mount, North Carolina, is a qualified, vested member in her employer’s disability insurance plan with Liberty Life.

Disability Blog & Cases:
Cigna denies Herff Jones Inc. employee disability benefits after she is diagnosed with multiple sclerosis

Karen Kolesky has filed a lawsuit against Herff Jones Inc., Cigna Insurance, and Life Insurance Company of North America in the United States District Court of Utah, Northern Division in an effort to receive her long term disability benefits as promised in her employee insurance policy. In possession of an employee insurance policy from her employer Herff Jones, Inc., Kolesky applied for long term disability benefits when she became disabled in November 2009.

Disability Blog & Cases:
A phlebotomist employed by Quest Diagnostics and diagnosed with RSD sues Aetna for denial of long term disability insurance benefits

In Sheila Pannozzo v. AETNA Life Insurance Company, Quest Diagnostics, Inc., Quest Diagnostics Long Term Disability Benefits Plan, filed in the United States District Court of the Middle District of Pennsylvania, Pannozzo and her Pennsylvania disability attorney accuse AETNA of abruptly and improperly terminating her disability benefit payments in violation of the Employee Retirement Income Security Act (ERISA) and 29 U.S.C. § 1132(a)(1).

Disability Blog & Cases:
CIGNA entitled to recover social security disability benefit overpayment

The United States Court of Appeals for the Third Circuit recently reversed a district court’s decision denying CIGNA recoupment of overpaid benefits.

Disability Blog & Cases:
What is Liberty Life Assurance Company of Boston trying to hide in denial of disability benefits?

This disability insurance case against Liberty Life Assurance is an example of the type of fight that a disability insurance company will engage in once a disability lawsuit is filed. It is often surprising that disability insurance companies will claim they are acting fairly, yet when you ask them to provide claims handling information they will aggressively object.

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Debra Letvinuck sued Aetna in District Court after Aetna denied her short-term and long-term disability benefits. After the District Court concluded that Aetna did not abuse its discretion in denying Letvinuck benefits, Letvinuck appealed to the 9th Circuit Court of Appeals.

Aetna both funds and administers the Plan's long-term disability benefits.

Aetna's dual role rendered it subject to a conflict of interest when making claims determinations. Because of the structural conflict of interest, Aetna's denial decision was reviewed while considering case-specific factors that may evidence a conflicted claim evaluation.

Failure to address a Social Security award of disability benefits offers support that the plan administrator's denial was arbitrary.

When reviewing Letvinuck's claim for benefits, Aetna gave no weight to the Social Security Administration's (SSA) decision that Letvinuck was disabled, nor did it provide an explanation. Although Aetna was not bound by the SSA's disability determination, the court noted that "not distinguishing the SSA's contrary conclusion may indicate a failure to consider relevant evidence."

During the ERISA appeal process, Aetna and its hired doctors acknowledged that Letvinuck had received an SSA award but no further explanation was provided. Only when Letvinuck called after Aetna had denied her appeal did Aetna offer an explanation by trying to distinguish its standard for disability from the SSA's.

Aetna failed to adequately tell Letvinuck what "additional material or information was necessary for her to perfect the claim, and to do so in a manner designed to be understood by the claimant.

Aetna based its denial of benefits substantially on the lack of recent neuropsychological testing that would objectively show Letvinuck's disability. However, Aetna did not ask Levinuck for more recent neuropsychological test results that showed her disability. More importantly, it failed to do so "at a time when she had a fair chance to present evidence on this point.

In essence, Aetna denied Levinuck's claim largely on account of the absence of objective medical evidence, yet failed to tell her what medical evidence it wanted.

Aetna's communications with Letvinuck's doctor asking for objective medical evidence was not sufficient.

Although Aetna presented evidence that it asked one of Levinuck's doctors for "clinically objective findings demonstrating… a further decline in her disability," the court found it inconsequential because the request was not specifically communicated to Levinuck.

Conclusion

The court ultimately concluded that Aetna had abused its discretion in denying Letvinuck benefits. Aetna had based its denial on the absence of specific medical evidence—evidence that Aetna did not tell Letvinuck she should obtain and send to Aetna to perfect her claim. Moreover, Aetna failed to meaningfully explain why it disagreed with the SSA's award of disability benefits.

The Court reversed Aetna's denial of long term disability benefits.  

About the author: Gregory Michael Dell is an attorney and managing partner of the disability income division of Attorneys Dell & Schaefer. Mr. Dell and his team of lawyers have assisted thousands of long-term disability claimants with their claims against every major disability insurance company. Request a free legal consultation here or call 800-698-9162.

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Resolved Cases:
CIGNA denies benefits after paying for 10 years, but Disability Attorney Stephen Jessup wins benefits for 60 year old client with fibromyalgia

For ten years our client was receiving long term disability benefits from CIGNA under an ERISA governed Group Disability Policy (Jaycor) due to a litany of medical conditions, which included Adult Onset Still’s Disease, Chronic Pain, Fibromyalgia and Fatigue. During the course of his claim and well prior to CIGNA’s termination of benefits, he had already met and passed the own occupation to any occupation definition change, had been approved for disability benefits by the Social Security Administration, and had even been approached by CIGNA on several occasions for a lump sum buy out of his policy. For all intensive purposes it would seem that at the age of 60 and the decade long history of his claim that CIGNA would not challenge the claim. However, CIGNA proved the adage that disability benefits are never guaranteed benefits.

Disability Blog & Cases:
California Court orders CIGNA to disclose amount paid to MES Solutions for medical reviews

CIGNA Insurance Company can run but they can’t hide. Recently, the US District Court for the Central District of California granted Plaintiff Bradley Wojno’s Motion to Compel Defendant CIGNA Insurance to reveal the extent of it financial relationship with MES Solutions. Mr. Wojno’s California disability attorney sought information from CIGNA that could unveil potential conflicts and biases of CIGNA’s hired gun doctors relied upon to terminate Mr. Wojno’s disability benefits.

Disability Blog & Cases:
Federal Judge orders Sedgwick Claims Management to pay disability benefits to PNC Financial Services Group, Inc’s Collection/Recovery Team Manager

Disability claimants need to be extremely cautious when dealing with Sedgwick Claims Management Service Inc. (Sedgwick). From our law firms’ experience of handling thousands of disability insurance claims, Sedgwick is one of the top three most difficult companies to deal with. Unfortunately, Sedgwick will capitalize on any opportunity to deny a claimant their disability benefits. This case discusses the unreasonable conduct used by Sedgwick to wrongfully deny disability benefits.

Disability Blog & Cases:
Standard Insurance Company’s attempt to dismiss disability insurance lawsuit is denied in-part by Florida Federal Judge

Disability claimant challenges Standard Insurance Company’s attempt to limit disability benefits to 24 months under the “Other Limited Conditions” provision.

Disability Blog & Cases:
Life Insurance Company Of North America denies disability benefits and battles claimant for 4.5 years in Federal Court

LINA should be embarrassed and show some respect for a former payroll clerk that had no ability to work due to numerous medical conditions. After litigating for more 4.5 years since her wrongful denial of disability benefits, Ms. Dupree finally received a ruling in her favor from the United States Court of Appeal. LINA fought this disability claim until there were no more courts left for them to appeal to. While, Ms. Dupree eventually won her disability benefits, it is sad that she had to battle for 4.5 years without any payment from LINA. LINA essentially left Ms. Dupree out in the cold. Unfortunately, Dupree’s only remedy is payment of her benefits, interest and attorney fees. This case is a prime example of the wrongful conduct by LINA and the exact reason that punitive damages should be allowed.

Disability Blog & Cases:
California Judge grants disability claimant’s request to investigate Hartford Life And Accident Insurance Company’s relationship with hired doctors

In Mary Carten vs. Hartford Life and Accident Insurance Company, Group Long Term Disability Plan for Employees Of FMR Corporation, the plaintiff brought the civil lawsuit in a California Federal Court under the Employment Retirement Income Security Act (ERISA) to challenge a denial of disability benefits made by the Hartford Life and Accident Insurance Company (Harford). The plaintiff requested an opportunity to conduct discovery into Hartford’s claims handling practices in order to determine if Hartford’s wrongful denial her long term disability benefits was done with a conflict of interest. It is ironic that Harford denies disability benefits and then tries to do whatever they can to hide the existence of their financial relationship with the doctors they hire. Hartford is suppose to be the fiduciary of Ms. Carten. Hartford’s actions clearly suggest that they are not acting in the best interest of Ms. Carten.

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Alleging that AETNA Life and Boeing have violated ERISA (Employee Retirement Security Act of 1974) by refusing to pay her earned disability insurance benefits, Deborah Rodriguez has filed a lawsuit in the United State District Court of Utah Central Division. Asking the Court to find in her favor against both AETNA and Boeing, Rodriguez and her Utah disability lawyer petitioned the United States District Court of Utah to order the defendants to:

• Pay her damages in the "amount equal to the disability benefits to which she was entitled through date of judgment" as well as unpaid disability benefits provided by law;
• Pay her pre- and post-judgment interest;
• Both be required to pay her any and all present and future disability benefits and any other employee benefits that are included in the subject plan;
• Pay her reasonable attorney fees and costs;
• Any other relief the Court finds appropriate; and
• Provide her with a "bound copy of the administrative record consecutively paginated."

Rodriguez and Her Utah Disability Lawyer Accuse AENTA of A Conflict of Interest

Rodriguez and her Utah disability lawyer allege that AENTA as the governing party for the payment of disability benefits as well as the denial of disability claims displays a conflict of interest when it comes to deciding who is awarded disability benefits under their policies and who is denied.

Aetna Denys Disability Benefits After Change of Definition from Own Occupation to Any Occupation

On May 25, 2008, Rodriguez ceased working at her job at Boeing as the result of a disability and was awarded disability benefits under her AETNA plan. Then, in October 2010, Rodriguez was informed that her benefits were terminated because AETNA's reviewers had determined that Rodriguez was capable of performing work other than her own occupation. Rodriquez appealed the termination, arguing that she did, indeed, still meet the criteria of her disability insurance plan to continue receiving disability benefits. Inevitably, AETNA didn't agree and in a letter dated March 10, 2011, informed Rodriguez that the decision to terminate her disability benefits would stand. With no other recourse, Rodriguez and her Utah disability attorney filed her complaint on June 13, 2011 claiming that AENTA was more concerned "over its own funds" and had allowed its decision-making to be influenced by that concern.

In her complaint, Rodriguez states her cause of action for plan benefits against Defendants AETNA and Boeing under 29 U.S.C. §§ 1132(a)(1)(B), pointing out that she qualifies to receive her disability benefits under her insurance plan until she reaches the age of retirement, that she remains disabled under her insurance plan requirements, and that AETNA and Boeing have breached their contractual agreement to provide her with those disability benefits.

Rodriguez and Her Utah Disability Lawyer Enumerate AETNA's Violations in the Administering of Her Disability Benefits Plan

Rodriquez and her Utah disability attorney allege that AETNA was "wrong under the terms of the Plan," that the "decision to terminate benefits and the decision-making process were arbitrary and capricious," that the "decision to terminate benefits was not supported by substantial evidence in the administrative record," and that Rodriguez has suffered damages as a "direct and proximate result of" the insurance company‘s conduct in the evaluation of her claim.

About the author: Gregory Michael Dell is an attorney and managing partner of the disability income division of Attorneys Dell & Schaefer. Mr. Dell and his team of lawyers have assisted thousands of long-term disability claimants with their claims against every major disability insurance company. Request a free legal consultation here or call 800-698-9162.

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If a claimant has a pre-existing condition they need to be aware of the pre-existing provision prior to filing an application for disability benefits and prior to stopping work. Almost all disability insurance policies contain pre-existing condition provisions.

Most pre-existing condition provisions state that if a claimant files a disability claim related to the same medical condition that existed within the 12 months prior to obtaining disability coverage, then the subject medical condition may be excluded from coverage.

In a recent lawsuit filed against Aetna Life Insurance in New York, the claimant’s disability benefits were denied due to a pre-existing condition. The claimant worked for Sunguard Data Systems, Inc. The New York District court agreed with Aetna’s denial of disability benefits due to a pre-existing condition and on Appeal the Second Circuit Court of Appeals affirmed the claim denial.

New York Disability Lawyer Argues that New York Law Should Apply

The court in this case applied Pennsylvania law even though the policy was delivered in New York. The policy stated that Pennsylvania law applied. The claimant’s New York Disability Lawyer was trying to argue that New York Law applied so that he could attempt to invalidate the pre-existing condition provision. New York has very specific laws which limit the scope of Pre-Existing condition provisions.

About the author: Gregory Michael Dell is an attorney and managing partner of the disability income division of Attorneys Dell & Schaefer. Mr. Dell and his team of lawyers have assisted thousands of long-term disability claimants with their claims against every major disability insurance company. Request a free legal consultation here or call 800-698-9162.

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Disability Blog & Cases:
California disability attorney sues Standard Insurance Company for denial of long term disability benefits payments to paraplegic

In the case of D. Nielsen Pollock Vs Standard Insurance Company, filed at the District Court for the Southern District Of California, the plaintiff complained that the Standard Insurance Company (Standard Insurance) have breached the Employee Retirement Income And Security Act Of 1974 (ERISA) and suing for the recovery of disability benefits under the terms of an employee benefit plan for which Standard Life is the insurer of benefits under the “DILLINGHAM CONSTRUCTION HOLDINGS INC. GROUP LONG TERM DISABILITY INSURANCE POLICY.”

Disability Blog & Cases:
Hartford Life And Accident Insurance Company denies disability benefits and prevails in lawsuit filed by operator for Mohawk Inc.

When making a case for a claim of disability benefits, it is essential that a claimant has strong medical support from treating physicians. The disability insurance companies are not under any duty to help a claimant further his or her claim for disability benefits. It is the burden of the claimant to ensure that he or she had provided sufficient proof of his or her disability status. This case of Almetta T. Campbell Vs. Hartford Life And Accident Insurance Company is a good example of how a disability insurance company can easily win a disability denial if the administrative record does not have strong medical support. Disability claimants must anticipate and be prepared for a change of the policies definition of disability from own occupation to any occupation. ERISA governed policies can make it difficult for disability claimants to prevail.

Disability Blog & Cases:
Court Of Appeals agrees with Texas Judge that UNUM did not abuse its discretion in denying Accenture LLP’s employee’s claim for disability benefits

In the case of Gwendolyn Byrd vs. UNUM Life Insurance Company Of America, the plaintiff filed a lawsuit in Texas federal court to challenge the Unum Life Insurance Company’s (Unum) decision to terminate her long term disability benefits after paying for 5 years. In the review for the abuse of discretion, the District Court granted summary judgment to Unum. The plaintiff is appealing this decision by the District court.

Disability Blog & Cases:
Appellate Court denies Liberty Mutual’s attempt to recover $163,661.57 in disability benefits paid to disability claimant and business owner

After 5 years of receiving long term disability benefits, Robin Dolan suddenly receives a letter in 2006 from Disability Reinsurance Management Services stating that her disability benefits had been wrongfully calculated and she must repay $163,661.57. Approximately 5 years after receiving this dreadful letter and extensive litigation, Ms. Dolan has finally received an Appellate Court ruling stating that Liberty Mutual was wrong in their interpretation of the disability policy. Unfortunately Ms. Dolan has had to suffer through the unreasonable actions of Liberty Mutual and their third party administrator DRMS.

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Connie White waited more than five years to file a lawsuit against MetLife for denial of her disability benefits. The law in Louisiana only provided Ms. White 5 years to file her legal action. The district court dismissed her disability claim and the 5th Circuit court of appeals affirmed the denial. Disability insurance claimants need to take timely action if a claim for disability benefits is denied. Failure to act within strict time lines can result in the inability to pursue a claim in court.

Failing to oppose Metropolitan's Motion for Summary Judgment, White alleges that her case was decided on the basis of her failure as opposed to the merits of her case. And even though the Court ruled to approve the insurer's motion, White was given a second chance to file her opposition. White had 10 days to file an opposing position to the original motion for summary judgment. Never filing anything acknowledging the motion, White, after the fact, claimed that the Court erred in its decision to uphold Metropolitan's decision to deny her long-term disability benefits.

The Fifth Circuit Court of Appeals Agrees to Review White's Case

As a result of her claim, the District Court of Appeals Fifth Circuit agreed to review the District Courts Summary Judgment de novo. White contended that the Court entered its ruling "solely because Metropolitan's motion was unopposed." And while the Court disputed this contention, it claimed that it granted the insurer's motion based on the evidence presented in Metropolitan's summary judgment motion.

The Fifth Circuit ruled that "the district court's ruling was correct on the merits." According to the terms of White's insurance plan, legal action cannot be filed "more than three years after proof of Disability," unless "the area where you live allows a longer period of time to file proof of Disability." In White's case, she let that time period expire. Consequently, her challenge to Metropolitan's benefit denial "was filed too late."

Finding of the Fifth Circuit Court in Connie D. White v. Metropolitan Life Insurance Company

The Circuit Court pointed out that since ERISA doesn't set a specific limitation period, state law applies. In Ms. White's case the law in Louisiana allows 5 years for a lawsuit to be filed. Unable to present a case that proves that Metropolitan did not materially misrepresent itself or its decision to deny White disability benefits or that "extraordinary circumstances" existed, White did not prevail in her appeal. Consequently, the Fifth Circuit Court allowed the District Court's ruling in White to stand. The lesson here is that timely filing of disability lawsuits and answers are imperative to a disability claimant's lawsuit being favourably ruled upon.

About the author: Gregory Michael Dell is an attorney and managing partner of the disability income division of Attorneys Dell & Schaefer. Mr. Dell and his team of lawyers have assisted thousands of long-term disability claimants with their claims against every major disability insurance company. Request a free legal consultation here or call 800-698-9162.

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Disability Blog & Cases:
Arkansas disability attorney filed lawsuit against Sun Life and Health Insurance Company on behalf of disabled Buford Media Group, LLC’s Office Manager for denial of disability benefits

In Kathryn McDaniel-Bowen vs Sun Life and Health Insurance Company F/K/A Genworth Life and Health Insurance Company, filed at the District Court for the Eastern District of Arkansas, the plaintiff Kathryn McDaniel-Bowen alleged that the Sun Life and Health Insurance Company (Sun Life) had breached its contractual obligations by denying long term disability benefits payments to her.

Disability Blog & Cases:
Disabled IKA Works, Inc. employee sues the Prudential Insurance Company of America to compel payment of disability benefits under an ERISA plan

A North Carolina disability attorney recently filed a lawsuit at the District Court for the Eastern District of North Carolina on behalf of a client against the Prudential Insurance Company of America (Prudential). In Cynthia Grimsley Vs the Prudential Insurance Company Of America, the plaintiff filed the complaint to seek the recovery of disability benefits under the Employee Retirement Security Act of 1974 (ERISA) from a Prudential issued Disability Plan.

Disability Blog & Cases:
Claimants under HSBC North America Holdings, Inc. Group Long Term Disability Benefits Plan sue Unum Life Insurance of America in Illinois and Nevada

Recently, two disabled employees of the HSBC Bank in Illinois and Nevada filed lawsuits against the Unum Life Insurance of America (Unum) for the wrongful denial of disability insurance benefits under the Employee Retirement Income Security Act (ERISA).

Disability Blog & Cases:
Tenet Healthcare Corporation employee sues UNUM Life Insurance Company Of America under ERISA for wrongfully denying disability benefits by disregarding attending physician’s medical opinion

An Alabama disability attorney recently filed a lawsuit at the District Court for the Northern District of Alabama against the Unum Life Insurance Company of America (Unum). In Joan Allred vs. Unum Life Insurance Company of America, the plaintiff Joan Allred sued Unum for the recovery of long term disability benefits due under her disability insurance plan sponsored by Tenet Healthcare Corporation.

Disability Blog & Cases:
Appellate Court upholds Prudential's decision denying disability benefits to insured when he refused to attend an IME Exam

Recently, the 8th Circuit Court of Appeals ruled that veteran career consultant, Anthony Polich, was not entitled to Long Term Disability (LTD) benefits after he refused to attend an Independent Medical Exam (IME) and to release relevant medical data requested by the LTD Plan administrator, Prudential Financial.

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Beneficiaries of disability insurance policies are seldom faced with an easy task when trying to claim disability benefits. Usually there are a long list of procedures with which claimants must follow before disability insurance companies approve their claim for disability benefits. Hence, it is advisable to have a disability attorney handle your claim for disability benefits at the very onset of your claim to ensure that your claim is handled properly. The case of Elizabeth Bailey as Administrator for the Estate of Adrian Douglas Bailey. Jr vs. Fortis Benefits Insurance Company (Fortis) is an example of why it is a prudent to have a disability attorney to represent you from the beginning of the claim process. Our law firm did not handle this disability lawsuit, however it is extremely strange why this case took more than 10 years to litigate.

The Alleged Facts Of The Case Against Fortis

The deceased participated in a Group Short Term Disability Insurance plan and an Accidental Death and Dismemberment Insurance Plan that was issued by Fortis. Due to severe depression, the deceased stopped working and applied for short term disability benefits. Fortis approved the deceased's claim for short term disability benefits on January 24th 1997.

During the interim period leading up to the suspension of the deceased's short term disability benefits by Fortis on June 6th 1997, the deceased was being treated by his attending psychiatrist. The deceased's attending psychiatrist noted that the deceased was making some recovery and also that "he wanted to stay at home [with his children] rather than returning to work."

Termination of Disability Benefits

Following the phone consultation by Fortis with the deceased attending psychiatrist on June 3rd 1997, Fortis suspended the deceased's short term disability benefits pending a review by the in-house Clinical Service Department. Following the review, it was concluded by Fortis's in-house psychiatrist that the deceased was no longer disabled. Hence, on August 4th 1997, following the completion of its review of the deceased's claim, Fortis terminated the deceased's short term disability benefits.

The Appeals

On September 17th 1997, the deceased's wife filed a complaint with the West Virginia Office of the Insurance Commission complaining of Fortis's decision to terminate the deceased's short term disability benefits. Fortis regarded this complaint as an appeal then invited the deceased to submit additional information and medical records to support this appeal.

On March 12th 1998, Fortis reaffirmed its previous decision to deny the deceased his claim for disability benefits. Fortis reasoning was that the deceased was originally cleared to work for a few months before his condition took a turn for the worse. Another complaint was filed by the deceased on October 27th 1998 with the West Virginia Office of the Insurance Commission when the deceased learnt that he was awarded Social Security Benefits(September 1998).

Again, Fortis regarded this complaint as an appeal by the deceased. However, while the appeal was being considered, the deceased passed away due to an unrelated medical condition. Just before the deceased passed away, he filed a claim for long term disability benefits and was informed that such benefits were not available while the appeal for short term disability benefits was pending. Upon the deceased demise, the plaintiff Mrs Bailey, the deceased's wife, filed a claim for life insurance benefits under the deceased's Accidental Death and Dismemberment Insurance Plan.

The Lawsuit Against Fortis

In September 2001, the plaintiff Mrs Bailey filed an ERISA lawsuit against Fortis seeking an award short term disability benefits, long term disability benefits and life insurance benefits on behalf for the estate of the deceased.

The Opinions of the District Court

The District Court in this case denied the plaintiff's motion for Summary Judgment but granted Fortis motion for Summary Judgment. There were two main issues for the Court to decide. One issue was the claim for short term disability benefits and the second issue was the claim for long term disability benefits together with the life insurance benefits.

The Short Term Disability Benefits

The Court reasoned that it is the burden of the plaintiff to submit satisfactory proof of his disability. The medical opinions relied upon by the deceased was insufficient to prove the deceased's disability status while on the other hand, there was evidence on record to show that the deceased was able to return to work as early as May 22nd 1997. In addition, the plaintiff's reliance on the Social Security Administration (SSA) determination of disability provided no basis for concluding that the deceased was disabled under the plan as the plaintiff failed to show that the Plan used a similar definition of disability as the SSA.

The Long Term Disability Benefits and Life Insurance benefits

According to Fortis, the plaintiff never filed a formal claim for long term disability benefits and life insurance benefits. As such, the plaintiff failed to exhaust all the administrative remedies before bringing the case to the Federal Court for judicial review. The Court ruled that the plaintiff's affidavit attesting that she applied verbally for these benefits was problematic as the affidavit was not part of the administrative record. Hence, the affidavit cannot be considered in the judicial review process. Furthermore, even if accepted, the Court stated that it only goes to show that the plaintiff did not apply properly for the above mentioned benefits as required under the terms of the Plan and hence left no factual record to assist the Court in reviewing the plaintiff's claim.  

About the author: Gregory Michael Dell is an attorney and managing partner of the disability income division of Attorneys Dell & Schaefer. Mr. Dell and his team of lawyers have assisted thousands of long-term disability claimants with their claims against every major disability insurance company. Request a free legal consultation here or call 800-698-9162.

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