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. To request a free legal consultation call 800-411-9085.

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. To request a free legal consultation call 800-698-9162.

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. To request a free legal consultation call 800-411-9085.

A Michigan disability attorney, on behalf of a disabled Michigan client, filed a lawsuit against the Unum Life Insurance Company of America (UNUM) at the District Court for the Western District of Michigan. In Kristina M. Arbelius V Unum Group D/B/A Unum Life Insurance Company of America, the plaintiff Kristina M. Arbelius alleged that UNUM committed a breach of a disability insurance policy that the plaintiff participated in.

The Statement of Facts in the Lawsuit

The plaintiff Kristina M. Arbelius was formerly a pacemaker technician working for the Marquette General Hospital. And as an employee of the Marquette General Hospital, she was covered by a disability insurance policy that was issued by UNUM. Under the disability insurance policy, the plaintiff was to be paid monthly long term disability (LTD) benefits in the event that the plaintiff was prevented from doing her job due to an injury or a sickness.

On September 18th 2007, as a result of pain associated with fibromyalgia and behavioral health symptoms, the plaintiff stopped working. The plaintiff, at the time of stopping her employment, was also suffering from diarrhea, fatigue, nausea and vomiting. As a result, the plaintiff was approved for LTD benefits on December 17th 2007. The plaintiff was also informed that she was subjected to a 24 month mental and nervous limitation.

On March 4th 2010, the plaintiff was sent for an independent medical examination conducted by UNUM’s hand-picked physician. Subsequently after the medical examination, the plaintiff’s LTD benefits were terminated by UNUM on June 15th 2010. According to the lawsuit, the discontinuation of LTD benefits was despite the fact that the plaintiff was having physical conditions and limitations confirmed by her treating physicians which rendered her unable to perform any type of employment. In support of the plaintiff’s argument, the Social Security Administration had also classified the plaintiff as being disabled with physical limitations and restrictions which are permanent and prevented her for from ever working again in any capacity.

As such, the plaintiff alleged that as a result of UNUM’s unlawful action, UNUM had:

  • Breached the terms of the disability policy
  • Acted in Bad Faith

The plaintiff further alleged that UNUM had caused her to suffer damages in the form of disability benefits not paid but should have been paid by UNUM under the terms of the policy in addition to the interest on that amount.

Relief Sought By the Plaintiff

Because of UNUM’s action, the plaintiff is seeking from the Court the following relief:

  • For an amount of money which will fully compensate her for losses sustained;
  • For costs, disbursements, and attorney fees;
  • For such other and further relief as the court deems just and equitable;
  • For an award of punitive damages;
  • For a determination outlining her future rights under the terms and conditions of the disability policy from Unum Group, d/b/a Unum Life Insurance Company of America.

In addition to the above mentioned relief sought, the plaintiff is also demanding a trial by a twelve person jury.

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. To request a free legal consultation call 800-411-9085.

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