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

Many employees rely on disability insurance benefits if they have been injured or have developed a sickness which prevents them from working. Disability insurance provides individuals with a percentage of his or her typical salary until the employee is able to return to work or turns age 65. However, what employees aren’t usually aware of is that as soon as disability benefits start, the disability insurance company wants them to stop  and they will use a wide range of tactics to make that happen.

As an attorney who has worked on thousands of long-term disability claims against major insurance companies around the country, I can tell you that insurance company tactics can involve undercover investigations, fact-twisting, and even having bias doctors subjectively determine that you are not disabled as in a recent disability insurance case.

Graciella Saffon vs. Wells Fargo

Graciella Saffon, an employee of Wells Fargo Bank, had suffered from degeneration of her cervical spine for several years. This condition was confirmed by several MRIs, X-rays and other medical information. In 2001, Saffon was in a car accident which aggravated her neck condition, leading her to quit her desk job and apply for long-term disability benefits with MetLife. After a certain amount of time, the insurance company began paying Saffon long-term disability. However, a year after she began receiving these long-term benefits, MetLife stopped paying them, informing her that she no longer met the terms of disability.

How MetLife Worked to Deny Mrs. Saffon Her Long-Term Disability Benefits

MetLife hired two different doctors to look over Saffon’s medical records, resulting in the following statements.

The first physician, Dr. Thomas, stated that “Saffon’s file lacks clear sequential, detailed and objective clinical information, which would completely preclude Ms. Saffon from an attempt to return to work.” After Dr. Thomas’s file review, MetLife stopped the long-term benefit payments. Saffon appealed MetLife’s denial and provided an updated cervical MRI with additional medical records. A letter from her neurologist, Dr. Kudrow, was also included, stating that she had undergone various pain treatments which were ‘without sustainable benefit’ and that she was unable to remain in a sitting position for more than a few minutes at a time.

Following the submission of the Appeal, a second doctor, Dr. Menotti, looked over Saffon’s records and claimed that her reports of headaches and chronic pain syndrome were not enough to keep her from working. MetLife then stated that Saffon had not supplied them with a functional capability evaluation so they were unaware of her ability to function at work. The appeal was denied.

Mrs. Saffon sued MetLife in California District Court, seeking back-payment of her disability income benefits. The District Court affirmed MetLife’s denial, and Mrs. Saffon continued her battle for disability benefits by filing an appeal with the 9th Circuit Court of Appeals. After reviewing the case, Judge Kozinski determined that MetLife had not given Saffon’s case a full and fair review for the following reasons:

“Its [MetLife] communications with Saffon and her doctors are hardly a model of clarity; they certainly do not explain 'in a manner calculated to be understood by the claimant' what Saffon must do to perfect her claim.” According to an earlier case, Booton vs. Lockheed Medical Benefit Plan, the insurance company must clearly communicate to the policyholder why their claim is being denied and what they must do in order to perfect it. Judge Kozinski was not convinced that this had happened in Mrs. Saffon’s case.

Information in Mrs. Saffon’s medical records was ignored or not considered fairly.MetLife’s complaint that they were not provided with a functional capability evaluation was not followed by a chance for Mrs. Saffon to provide that information to them.

Judge Kozinski remanded the case back to the California District court, requiring that they give a full and fair look at Mrs. Saffon’s case taking into account the flaws in their review process and the ERISA laws. This was a victory for Ms. Saffon, who was given a second chance to show that she most certainly did deserve disability benefits due to her inability to work. However, one has to note that Mrs. Saffon did everything she could to show this in the first place, and had MetLife acted reasonably, Mrs. Saffon would not have had to go without her disability benefits or go through a painful and drawn out battle in court at all.

*About the Author: Gregory Michael Dell is an attorney and managing partner of the disability income division of the firm Dell and Schaefer (www.diattorney.com). He has assisted thousands of claimants with their claims for long-term disability benefits. He can be reached at 888-SAY-Dell or gdell@diattorney.com
 

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Prior to September 11, 2001 our client, Mr. B, was a government securities repo trader. His office was located on the 26th Floor of Tower 1 of the World Trade Center. On the morning of September 11, 2001, Mr. B reported to work at his brokerage firm and started his day buying and selling government securities for his commercial clients, institutions such as Bank of Tokyo and Lehman Brothers. At around 8:45 a.m., Mr. B and his co-workers heard a loud explosion and felt the building shake, ceiling tiles began falling in Mr. B’s office and thick smoke filled the hallways and stairwells. Fifty minutes later, after descending 26 floors of smoke, heat, and chaos, Mr. B was out of Tower 1. Mr. B’s life was forever changed that day and nightmares of his escape would haunt him for years.

Mr. B, like many of his co-workers, returned to work, this time across the river in New Jersey with an unobstructed view of the altered New York City skyline. For two years following September 11th, Mr. B reported for work despite battling daily depression and severe anxiety resulting from Post Traumatic Stress Disorder. He was no longer the same person. Mr. B’s medical condition made it difficult for him to work. The nightmares were daily and he was finding it impossible to effectively perform his job duties in the high stress and cut throat trading pit in which he worked. Mr. B sought help from mental health experts, but despite his treatment, his symptoms continued to worsen to the point that he was forced to stop working and file for long-term disability benefits with his disability insurance carrier. Mr. B had purchased his long-term disability policy from his insurance agent approximately 10 years prior to his date of disability.

In 2003, upon review of the abundance of medical support from his therapist and treating psychiatrist, his disability insurer determined Mr. B was totally disabled and began paying benefits. For approximately three years, Mr. B’s long-term disability insurance carrier paid him without any problems. Shortly thereafter, Mr. B’s disability insurer began questioning the extent of his limitations and restrictions. It was at this point that Mr. B hired Attorneys Dell & Schaefer to assist him in dealing with the various requests which were being made by his disability insurance company.

Mr. B’s disability carrier requested that he undergo an independent medical examination. Not long after the IME the insurer terminated Mr. B’s benefits relying greatly on the opinion of the insurance company’s hired independent psychiatrist and claiming that Mr. B was at best partially disabled but since he was not gainfully employed - a requisite to being partially disabled under Mr. B’s disability policy - he was not eligible to receive partial disability benefits.

In 2006, Attorneys Dell & Schaefer appealed the denial of benefits with the disability insurer and successfully had the denial overturned. The disability carrier continued to pay total disability benefits for another 2 years, however, in late 2008 the disability carrier sought the opinion of the same independent psychiatrist and again found cause to terminate benefits. Attorneys Cesar Gavidia and Gregory Dell began preparing the case for litigation. Prior to filing suit, the parties agreed to participate in mediation as a method of attempting to resolve the dispute. Mediation took place in New York City where the parties were able to successfully reach a confidential settlement which involved a complete lump-sum buyout of Mr. B’s long-term disability policy.
 

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