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

Walter Pettway was employed with ADP (NASDAQ: ADP), as a principal consultant, beginning in 1994.  Mr. Pettway’s job required him to travel the United States helping large corporations with computer processes.  In the 1970’s, Mr. Pettway had undergone a cervical fusion at the C6-7 level and at the C5-6 level in 1999.  In the summer of 2002, Mr. Pettway suffered a fall which aggravated his condition, so that he experienced issues with his neck, lower back, left arm, right and left leg weakness and numbness in his fingers.  In October 2002, Mr. Pettway began treating with and orthopedic surgeon, Dr. Ragab.

Mr. Pettway underwent a cervical discectomy and fusion from C3 to C5 with an allograft and placement of anterior instrumentation on January 21, 2003.  Because of continued finger numbness and neck pain, Mr. Pettway underwent another surgical procedure to remove the hardware on June 24, 2003.  Continued pain led Mr.Pettway’s orthopedic surgeon to suggest his pain and numbness was a result of scarring from past surgeries.

On January 20, 2003, Mr. Pettway applied for long-term disability benefits with Prudential as outlined in the plan he was part of with his workplace.  He claimed disability for the recent cervical issues, pain and numbness as well as a history of diabetes and high blood pressure. Submitted with the disability claim was a statement of Dr. Ragab, indicating that the patient had been diagnosed with cervical spondylosis and herniated nucleus pulposus.  Prudential initially approved Pettaway’s claim for disability benefits.

Disability benefits were received until December 1, 2003 because Prudential stated that Mr. Pettway was no longer qualified to receive them.  At this point with the policy, Mr. Pettway could only be considered disabled if he were not able to perform the duties of any job as opposed to only the duties of his job.  Along with an appeal on November 25, 2003 Mr. Pettway submitted a statement from Dr. Ragab on December 5, 2003, stating that Mr. Pettway was, “unable to perform the duties of any gainful occupation which he is reasonably fitted by education, training and experience.”

A Prudential-initiated independent medical exam by Dr. Thomas Cullom, a neurological surgery specialist, was scheduled on January 7, 2004.  Dr. Cullom concluded that Pettway was unable to perform the duties of his own current occupation.  Prudential reinstated benefits on January 22, 2004.  Multiple attempts to perform surveillance on Mr. Pettway happened between February 2004 and November 2007.  At one point, Prudential had video of a man they thought was Mr. Pettway.  However, it was proven not to be and those videos were disregarded.  There was one video of Mr. Pettway driving to a car rental location, placing two bags in the car and driving for an hour.

Another independent medical examination was scheduled with Dr. Jo Lynn Polk, on November 16, 2007.  After examining Pettway, reviewing his medical records, and watching the surveillance video of Mr. Pettway, Dr. Polk concluded that the patient’s, “self-reported functionality is not consistent with the activities noted on the surveillance.”

Other claims by Dr. Polk include, "(1) although he claims his left hand is weak, there was no atrophy of his left hand muscles; (2) although he says he has numbness in his left hand, there was only a slight sensory deficit which would impart minimal impaired function of the left hand; (3) although he says he can sit for only 30 minutes at a time, he sat on the examining room table for one hour during my interview; and (4) although he says he needs assistance standing and wiping himself after bowel movements, during my evaluation he demonstrated independence with standing after sitting and had adequate right shoulder internal rotation to wipe himself after bowel elimination."

As far as standing without assistance, Dr. Polk repeated only what a nurse relayed to her – these observations were not made firsthand.

Prudential had an in-house physician, Dr. Day, review Dr. Polk’s report and he concluded, “I would agree with the conclusion Dr. Polk noted that the claimant has sustainable work capacity at least at a sedentary level. There were several inconsistencies in the physical examination by Dr. Polk.”

In another appeal, Mr. Pettway submitted letters from three physicians (Dr. Ragab, Dr. Cullom and Dr. Bouldin), which disagreed with Prudential’s findings.  Prudential denied benefits and stated in a letter sent June 11, 2008 that Mr. Pettway has the functional ability to perform duties of jobs other than his own, which he is well-trained and qualified for.

In the United States District Court for the Southern District of Mississippi, Hattiesburg Division, it was found that Prudential completely ignored irrefutable evidence of Mr. Pettway’s condition by his treating physicians.  Instead they relied on Dr. Polk’s assessment, a physician who saw him for less than an hour.  The video evidence was disregarded, both because Prudential had been unsuccessful at surveying Mr. Pettway most of the time and had blundered in their attempts to do so and because nothing in the videos suggested that Mr. Pettway was able to perform the duties of any job with reasonably continuity.  Because of this, the court ordered Prudential to reinstate Mr. Pettway’s long term disability benefits.

*About the Author: Gregory Michael Dell is an attorney and managing partner of the disability income division of Attorneys Dell and Schaefer (www.diattorney.com). Mr. Dell and his team of lawyers have assisted thousands of long-term disability claimants with their claims against every major disability insurance company. He can be reached at 888-SAY-Dell or gdell@diattorney.com.

• Email This
• Print
• Comments
• Trackbacks

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
 

• Email This
• Print
• Comments
• Trackbacks

Our client, a general surgeon for 25 years, was forced to stop performing surgery due to chronic degenerative cervical disc disease. Fortunately, our client had purchased a long-term disability policy from Paul Revere Insurance Company (acquired by Unum), during the early years of his career. The Unum long-term disability policy provides a monthly disability benefit in excess of $12,000 in the event our client is unable to perform the substantial and material duties of his occupation.

Disability insurance attorneys Dell & Schaefer were retained in order to advise our client of his contractual rights to long-term disability benefits and to assist with the submission of his application for benefits. Through a coordinated effort led by Attorney Gregory Dell, our client’s physicians, employer, and accountant provided all of the information necessary to submit the application for long-term disability benefits. Once the application was submitted, Unum requested to speak with our client, and that conference was attended by Attorney Gregory Dell and his client. Within 30 days of submitting the application for long-term disability benefits our client’s claim for long-term disability benefits was approved. Dell & Schaefer was able to assist our client in obtaining a quick approval for long- term disability benefits, as Dell & Schaefer has submitted disability applications on behalf of hundreds of disability claimants. Attorneys Dell & Schaefer continues to handle our client’s long-term disability claim on a monthly basis and Unum is required to direct all communications directly to our office.

Attorney Gregory Dell stated, “It is important to anticipate and be prepared to submit every relevant document the disability carrier may request, otherwise a claimant’s application process can take six months to a year to obtain a claim decision. After deposing the claim representatives and reviewing the internal claims handling manuals of every major long-term disability insurance company, my team of lawyers has a great understanding of exactly what the disability insurance companies need to see in order to approve a claim.”

Attorneys Dell & Schaefer represents disability claimants at all stages of their claim for long-term disability benefits. For additional information call 888-Say-Dell or visit www.diAttorney.com.
 

• Email This
• Print
• Comments
• Trackbacks

Our client, a dentist working in the capacity of a director of clinical technology for a well known company, began experiencing problems with his balance in March of 2009. In his role as director of clinical technology he was required to give lengthy presentations and speaking engagements, as well as be on the cutting edge in dental procedures. His initial balance problem quickly progressed leading to the cancelation of scheduled presentations, and our client seeing his doctors for testing. Test results indicated that he had a life-threatening brain tumor. Within a month and a half of first being seeing for the brain tumor he was undergoing brain surgery to remove the cancerous mass. The surgery was successful in removing the majority of the tumor, but resulted in loss of hearing in his left ear, cognitive dysfunction, and the exacerbation of a cervical neck condition brought on by years of dentistry. In the aftermath of the surgery his balance and equilibrium problems worsened, he began to experience severe headaches when working at the computer, and the surgery exacerbated his cervical neck condition. Hopes of returning to work after a short rest period from the surgery quickly vanished and he contacted Dell and Schaefer to assist in the filing of his disability claims.

Attorneys Gregory Dell and Stephen Jessup gathered all of the medical, financial and occupational information necessary to submit our client’s claim for disability benefits. Attorneys Dell & Jessup obtained supporting documentation from our client’s treating physicians and assisted our client with his application for disability benefits. Our client was further advised of the importance to have his doctors continue to document his restrictions and limitations. Within a week of filing for benefits, our client was approved for disability benefits. Attorneys Dell & Schaefer continue to handle our client’s disability claim on a monthly basis.
 

• Email This
• Print
• Comments
• Trackbacks

Our client, a chiropractor, was involved in motor vehicle accidents in 2005 and 2007, which resulted in him suffering from lumbar radiculopathy and cervical discogenic disease. As a solo practitioner and business owner he attempted to continue to work through the pain by working in a reduced fashion. He modified the techniques he employed for certain chiropractic procedures, and had to eliminate others all together. By the middle of 2008 the worsening pain became such that he realized he would no longer be able to work as a chiropractor. By the end of 2008 he closed his chiropractic office and filed for long term disability benefits under his AXA Equitable Policy.

Shortly after filing for long-term disability benefits, Attorneys Dell & Schaefer was retained to assist with the approval of long-term disability benefits. Attorneys Gregory Dell and Stephen Jessup took over the handling of the long-term disability claim, and advised Disability Management Services (DMS) that they shall not contact our client. DMS administers the AXA Equitable policy and began making numerous and lengthy requests for documentation from our client. DMS is a third party disability benefit administrator, which means that they are a 3rd party company that has been retained by AXA Equitable to review and handle all aspects of our client’s disability claim. DMS administers claims for multiple long-term disability insurance companies and Dell & Schaefer has handled numerous claims against DMS.

Throughout the application process, Attorneys Dell & Schaefer responded to multiple request for information and assisted our client with the preparation of all claim forms. DMS requested a field interview with our client which Dell & Schaefer attended and prepared the client. All requests for information and questions were promptly answered by Attorneys Dell and Jessup. Despite answering all of DMS’s requests for information, DMS failed to make a timely determination as to our client’s eligibility for benefits under his long-term disability policy. As a result of this attorneys Dell and Jessup demanded DMS provide our client with benefits or a lawsuit would be filed. In response to the demand DMS forwarded a check to our client representing five months of disability benefits, which were not made under reservation of rights, while they continue to evaluate the disability claim on a monthly basis. Attorneys Dell & Jessup will continue to handle all aspects our client’s long-term disability claim on a monthly basis.
 

• Email This
• Print
• Comments
• Trackbacks