Posted on January 5, 2010 by Gregory Dell

Third Circuit Court of Appeals Upholds Hartford's Denial Of Long-Term Disability Claim Based on Pre-Existing Condition Defense

The Third Circuit Court of Appeals recently rendered a very difficult decision in favor of Hartford Insurance Company dealing with the interpretation of pre-existing condition clauses in long-term disability income policies. The three judge panel ruled 2-1 in favor of upholding Hartford’s denial of disability benefits. The law in each state is different for pre-existing conditions, therefore a disability claimant should consult with a disability insurance attorney prior to filing a claim for benefits.

In the case we are going to consider here, Jay Doroshow v. Hartford Life and Accident Insurance Company, two judges found Hartford had been neither capricious nor arbitrary when the insurance company denied Doroshow’s claim for long-term unemployment. The third judge disagreed, arguing in his dissent that Doroshow had not received treatment for the condition that precipitated his claim with Hartford. We will have to look at the backdrop against which this case developed.

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Posted on April 9, 2009 by Gregory Dell

Unum Provident's Appeal of Long Term Disability Benefits Awarded to a New York Tax Attorney Is Denied

The Second Circuit U.S. Court of Appeals has denied First Unum Life Insurance Co.'s request to reconsider a decision in which it found the company arbitrarily denied long-term disability benefits to a tax attorney with colon cancer.  First Unum, a unit of Unum Group (NYSE: UNM), filed the petition for rehearing with the New York-based federal appeals court in January, saying that the court "misapprehended key facts and law" (BestWire, Jan. 9, 2009). Attempts to speak with Unum Group to see if First Unum plans to appeal to the U.S. Supreme Court were not immediately successful.  According to the December 2008 decision, written by Circuit Judge John M. Walker Jr. for a three-judge panel, First Unum operated under a conflict of interest because it was both the claims administrator and payor of benefits.

 
John McCauley, the cancer sufferer and disability claimant, was a senior vice president and tax attorney at Sotheby's Service Corp. in April 1991, when he was diagnosed with advanced colon cancer. First Unum was Sotheby's long-term disability insurer under an Employee Retirement Income Security Act-governed plan.  He sued First Unum in the U.S. District Court for the Southern District of New York, alleging bad faith denial of his claims under an original and conversion policy. The court ruled in favor of First Unum, but the Second Circuit reversed. The Second Circuit Court of Appeals cited the U.S. Supreme Court's new standard for assessing the impact of a plan administrator's potential conflict of interest as outlined in its 2008 decision, "Metropolitan Life Insurance Co. vs. Glenn". The Second Circuit, in the December 2008 ruling, sent the case back to the district court to enter summary judgment in McCauley's favor and to calculate benefits dating back to 19 95, as well as costs and attorney fees.  Previously, First Unum said it thinks the negative comments included in the decision and the court's "reliance on old ...articles and television programs, to be in error, and we believe the court overlooked key facts and law".
Unum Group was formerly known as UnumProvident Corp.
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Posted on January 17, 2007 by Gregory Dell

MetLife Ordered to Pay Disability Benefits Beyond 24 Months For a Claimant with Both Mental and Physical Disabilities

Mr. Mark J. Schwartz, an accountant, was insured under his employer’s group disability plan, sponsored by Metropolitan Life Insurance Co. (MetLife), which limits disability benefits for mental illness to 24 months, but to age 65 for a physical disability.

After major heart surgery in 1999, Mr. Schwartz was diagnosed with post bypass anxiety syndrome resulting in elevated blood pressure, dizziness and chest pain. Upon recommendation by his doctor, Mr. Schwartz applied for total disability benefits that year. The application was granted however MetLife concluded the disability was a result of a mental condition, limiting his benefits to 24 months. In 2001, Mr. Schwartz provided additional medical information arguing his disability was physical in nature. After reviewing these records, MetLife’s doctor concluded there were no physical impairments preventing Mr. Schwartz from working. In May 2001, Mr. Schwartz underwent angioplasty and stent surgery. MetLife denied his claim and terminated his benefits in July 2001. Mr. Schwartz sued in U.S. District Court for the District of Arizona seeking reinstatement of benefits under the Employee Retirement Income Security Act (ERISA).

After reviewing the evidence, Judge Mary H. Murguia held that MetLife could have determined Mr. Schwartz’s disability was physical and under estimated the seriousness of Mr. Schwartz’s heart condition. “Plaintiff’s medically documented disability based on a combination of physical and mental impairments warrants the payment of benefits beyond the 24-month period” stated Judge Murguia.

Mark J. Schwartz v. Metropolitan Life Insurance Co., et al., No. CIV-01-2075, D. Ariz.; 2006 U.S. Dist.
 

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