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

Our client was a successful, experienced financial advisor who operated her own practice. In December of 2008, while stopped at a red light, her car was hit from behind by a cement mixer. As a result of the accident she sustained multiple herniated disks in her neck, and pain that radiated into her shoulders and down her arms. Despite her efforts to continue working following the auto accident, she was unable to do so. No longer able to advise her clients as to important financial decisions affecting their futures, she was left with little choice but to apply for long term disability benefits under her individual disability policy purchased from Unum. In April of 2009 she contacted Dell and Schaefer to assist with her application for long-term disability benefits. Despite our client contacting us in April of 2009 and her continued attempts to work, we were able to prove that her date of disability should be the same as the date of her accident.

After gathering all the information necessary to properly present her claim for disability benefits, Dell and Schaefer submitted her disability application in mid May 2009. From the time the application was submitted, Unum began to delay the processing of her claim. Despite overwhelming medical support of a severe neck injury, which her doctors indicated would require surgery to repair; Unum sent her claim for two separate medical reviews. Unum had our client’s reviewed by both their in-house medical doctor and an outside medical doctor. Unum required an hour long field interview, asking questions already answered in her application and in subsequent responses to requests for information, all in an attempt to find any inconsistency with which to deny her claim. Unum continued to “evaluate” her claim for over a month and a half, citing medical records review and vocational reviews as reasons for the delay. Attorneys Dell and Schaefer sent multiple letters and made numerous phone calls to demand payment of disability benefits to our client.

In August of 2009, unable to deal with the pain and discomfort, she underwent surgery to fuse two vertebrae in her neck. Attorneys Dell and Schaefer contacted Unum immediately regarding the same and forwarded the applicable records to ensure Unum would not try to delay any longer. Within a week Unum finally approved her claim and forwarded a check for all back and present benefits due. However, this will most likely not be the end of the fight with Unum. Within two weeks of her surgery Unum was already demanding updated forms inquiring as to her intent to return to work and her daily activities. Unum made it very clear that approval for long term disability benefits is a month to month evaluation. Attorneys Dell and Schaefer will continue to fight for her rights to long-term disability benefits while she focuses on recovering from surgery.

Attorneys Gregory Dell and Stephen Jessup assisted her in applying for, and maintaining her benefits. Attorneys Dell and Schaefer assists numerous clients each month in maintaining their claim, acting as the liaison between the insurance company and our clients.

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Dr. C, a dentist, came to Attorneys Dell & Schaefer in 2006 seeking assistance in submitting applications for long-term disability benefits. In 1999, Dr. C began noticing a slight tremor in his right hand while writing and at times while holding a dental instrument. He immediately sought care from a neurologist, who after examining Dr. C, determined that the tremor was likely stress and anxiety related. Dr. C continued working and operating his dental practice with the hopes that his slight tremor would resolve.

Unfortunately, the tremor did not cease, in fact, it worsened. Dr. C began suspecting that perhaps the tremor was not simply stress, but something more serious and complicated. Beginning around 2002, Dr. C was forced to reduce his patient load due to his hand tremor and stop performing major dental procedures, which produced a majority of the income in his practice. Dr. C was having great difficulty maintaining his dental practice and he made the difficult decision to sell his practice before matters got financially worse. Dr. C found a buyer for the practice and negotiated an agreement where he would stay on as an independent contractor assisting in the transition of the practice to the new dentist. By mid 2003 the transition of the practice was complete and Dr. C accepted a new position with a dental practice performing minor dental procedures and cleanings. Dr. C’s symptoms continued to progress between 2003 and 2006, eventually causing him to go and see his neurologist again who advised him to stop all forms of general dentistry as of November 2006.

Prior to November 2006, Dr. C never understood what it meant to be “disabled”, as defined in his disability policy. He had always thought that “disability” was the loss of sight, the loss of a hand, or some injury or illness which would cause him to be completely incapable of performing activities of daily living. Dr. C had not realized, until Dell & Schaefer brought it to his attention, that pursuant to the unique terms and conditions of his disability policies, that “disability” also meant experiencing a 20% or greater loss of income in your occupation due to an illness or an injury. In early 2007, Dr. C submitted his applications for long-term disability benefits and claimed a disability date of May 2002, which was when he first began to loose income as a result of his hand tremor. The disability carrier approved the claim as of November 2006, but denied disability benefits for the period of May 2002 through October 2006, claiming that the insured’s late notice caused prejudice to the insurers, and even if the insurers had the ability to conduct a contemporaneous review, under their review of the claim Dr. C had not suffered the requisite loss of income to qualify for disability benefits. Under Florida law and the law of most states, failure to provide timely notice of claim to a disability carrier, in Dr. C’s case 90 days, can create a presumption of prejudice to the insurance carrier and an effective affirmative defense in the event of a suit.

Dr. C’s disability policy stated that if he was disabled prior to age 60 then he would receive disability benefits for his lifetime, otherwise the benefits would terminate at age 65. Dr. C turned age 60 in February 2006, and the disability carrier claimed he was not disabled until November 2006. The policy defined disabled as either residually or totally disabled. The carrier continued to deny benefits for anytime before November 2006 and advised Dr. C that benefits would terminate at Age 65. Attorney’s filed a lawsuit on behalf of Dr. C for breach of contract and seeking recovery of disability benefits due from May 2002 through October 2006. During litigation the insurance company raised the following defenses:

1) Dr. C failed to provide timely notice of claim;
2) Dr. C failed to reasonably treat with a physician from May 2002 through October 2006;
3) Dr. C failed to suffer a loss of income due to illness or injury;
4) Dr. C failed to comply with the “proof of loss” requirements of his policy.

Despite the difficult legal hurdles facing Dr. C’s case, Cesar Gavidia, Jr. and Gregory Michael Dell of Dell & Schaefer’s disability litigation team were able to successfully negotiate a confidential settlement that included past and future lifetime disability benefits.
 

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Our client, a chiropractor, fractured his arm and tore his rotator cuff as a result of a skiing accident in March 2008. Despite his injuries our client attempted to return to full-time chiropractic performing manual spinal adjustments. His treating physicians advised him that he should cut back on the number of patients he was treating pre-accident and see if he can handle a limited patient load. This client came to Dell & Schaefer for guidance and help in filing his disability claim.

After reviewing the client’s long-term disability policy he had purchased from National Life of Vermont and now administered by UNUM, Attorneys Gregory Dell and Robert Kerr advised him of his options moving forward. The client retained Dell & Schaefer to advise him of his contractual rights and to guide him through the process of applying for long-term disability benefits. During the application process, UNUM requested several years of tax returns, profit and loss statements, CPT annual and monthly production reports and medical records from all of his treating physicians. Despite overwhelming and repeated documentation from the client’s treating physicians that our client was unable to perform his job as he once did, Unum continued to refuse to pay our client, claiming they did not have sufficient evidence of his inability to perform his job as a chiropractor.

We performed an extensive analysis of our client’s activities for the time periods before and after his accident. Based on our client’s billing, it was clear that the time he was spending performing manual manipulation – the basis of his practice – was significantly decreased following his accident. This information was presented to Unum as further evidence of his inability to do his job as a chiropractor, along with the numerous doctors’ reports where his doctors repeatedly told him that he should not be performing manual manipulations. It was our opinion that the client was clearly eligible for partial disability benefits as a result of his loss of income caused by his injuries.

After several months of providing sufficient evidence of disability and Unum refusing to pay our client, Dell & Schaefer filed a complaint with the Florida Department of Financial Services in anticipation of litigation. Shortly thereafter, Unum made the decision to pay our client, finally agreeing that our client is partially disabled pursuant to the terms of his disability contract.

Since originally reducing his hours, our client has had to stop working, and as a result sold his practice. He is now totally disabled from his former occupation as a chiropractor specializing in spinal adjustments. Dell & Schaefer is handling his transition from partial disability to total disability and will monitor our client’s claim moving forward.

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