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

Our client, an Engineer Manager specializing in Fluid Power Engineering, suffers from severe Coronary Artery Disease. Despite the fact multiple diagnostic tests performed indicated there were no abnormalities with his heart, he suffered two heart attacks in the span of six months. Following his second heart attack in July 2006, he applied for long-term disability benefits under his employer’s long term disability plan through Prudential. Prudential initially approved his claim for disability benefits, and following his elimination period he began receiving long term disability benefits in September 2006.

In July 2008, Prudential terminated his disability benefits, citing a lack of objective medical evidence to support his disability and resulting inability to perform his job. Upset and confused by Prudential’s denial of his disability benefits, he contacted Attorneys Dell & Schaefer to retain our services in the filing of his appeal. Review of the claim file by Attorneys Gregory Dell and Stephen Jessup revealed that Prudential was not properly classifying or recognizing the true nature of his pre-disability occupation with his employer. Therefore, Prudential was not reviewing his medical condition as it related to his ability to perform the duties of his occupation. Dell and Schaefer attacked Prudential on this fact, submitting an initial appeal in January of 2009 that detailed the duties of his occupation and how, in light of these duties, his coronary artery disease prevented him from being physically unable to perform those duties. Prudential reviewed the initial appeal and within three weeks sent a second denial letter.

Review of Prudential’s second denial letter clearly indicated that Prudential did not even take into consideration the information submitted in the first appeal regarding our client’s occupation and again cited no medical evidence to support disability. A second appeal was filed in late July 2009, which once again illustrated how Prudential was improperly reviewing our client’s claim for benefits in violation of ERISA. Attorneys Dell and Schaefer argued that although objective tests such as EKG’s indicated no abnormalities, the practice of medicine is not an exacting science, and that the only truth in our client’s medical history is that he repeatedly “passed” testing, and experienced a heart attack upon returning to work not once, but twice.

Following the submission of the second appeal, Prudential took the full 45 days to review his claim, and even requested an extension of an additional 45 days. During this period Prudential requested our client undergo an Independent Medical Examination, where once again diagnostic testing appeared normal, but his performance on other tests indicated the severity of his impairment. Faced with the reality of our client’s medical history, and the fact they had improperly reviewed his claim for benefits, Prudential reversed their decision to terminate our client’s benefits and paid all past due disability benefits. Fortunately our client was able to prevail without the need to file a lawsuit.

Attorneys Dell and Schaefer have represented hundreds of clients who have had benefits terminated or denied under Group Long Term Disability Policies. Attorney Stephen Jessup or Gregory Dell can be reached at 800-828-7583.
 

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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.
 

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Our client, a financial advisor, was first diagnosed with fascioscapulohumeral muscular dystrophy (FSHD) in 2002. FSHD is a neuromuscular disease which causes progressive skeletal muscle loss and weakness, defects in the biochemical, physical and structural components of muscle and the death of muscle cells and tissue. FSHD is a severely disabling condition and is the second most prevalent muscular dystrophy affecting adults. Despite our client’s diagnose he continued work with his illness for several years. Beginning in 2003 and 2004, our client began experiencing noticeable symptoms of aches, pains, difficulty speaking, discomfort and limitations in doing some normal everyday tasks and activities. Over the past two years our client’s symptoms rapidly increased and intensified, to the point it was becoming impossible to perform his occupation as a financial advisor.

Our client contacted Attorneys Dell & Schaefer to assist with the filing of application for long-term disability benefits with Mass Mutual and other long-term disability insurance companies. Attorneys Gregory Dell and Cesar Gavidia worked with our client to gather all of his medical records, financial and occupational information. Our client’s disability policy stated that he would be eligible for long-term disability benefits if he was unable to perform the duties of his occupation. Attorneys Dell & Schaefer submitted our client’s application with extensive addendums attached and the claim for long-term disability benefits was approved within 45 days. As long as our client remains eligible for long-term disability benefits, he will receive approximately $12,000 a month until her turns age 65. Attorneys Dell & Schaefer continues to assist our client with the monthly maintenance of his claim with MassMutual.
 

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Our client, a general dentist, purchased a long-term disability policy from Berkshire Life Insurance Company of America. The policy defined “disability” as the inability to perform the substantial and material duties of his regular occupation. Our client maintained a solo dental practice since 1995. After several years of practice, Dr. Q began experiencing back pain which made it difficult for him to bend over patients for long periods of time and perform most of his dental procedures. The pain continued to worsen as time went on. Dr. Q’s treating neurologist diagnosed Dr. Q with lumbar degenerative disk disease and associated radiculopathy. Eventually, the pain forced Dr. Q to put his practice up for sale and discontinue the practice of dentistry.

Knowing that the application process for long-term disability benefits could be complicated, Dr. Q contacted Dell and Schaefer to assist him in submitting his claim for long-term disability benefits. Attorneys Gregory Dell and Cesar Gavidia gathered all of the medical, financial, and occupational information necessary to submit Dr. Q’s claim for long-term disability benefits. Berkshire delayed payment of Dr. Q’s disability claim as Dr. Q. had began working in a new occupation as a dental professor. After field interviews with Berkshire and our client, Attorneys Dell & Schaefer were able to prove that the material duties necessary to be a professor are not similar to the material duties required to work as a solo general dentist. Once Berkshire accepted that Dr. Q could no longer practice dentistry on patients, they agreed to pay long-term disability to our clients. Berkshire agreed to pay benefits just prior to Attorneys Dell & Schaefer filing a lawsuit for their failure to pay. Attorneys Dell & Schaefer continue to maintain Dr. Q’s long-term disability claim with Berkshire on a monthly basis
 

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Since late 2004, our client, Sumiko Besser has been battling Prudential Insurance Company in an effort to secure her long-term disability benefits. Prudential currently owes her in excess of $900,000 in unpaid long-term disability benefits. Our client became disabled on May 10, 2004, as a result of chronic neck pain caused by multi-level degenerative disk disease. Attorneys Dell & Schaefer submitted two administrative appeals to Prudential and in early 2008 filed a lawsuit in United States District Court of Hawaii. On May 19, 2009, Attorneys Gregory Dell and Leonard Feuer presented our client’s case at trial and on July 14, 2009 the Federal Judge issued a 20 page opinion reversing Prudential’s denial of benefits. Motions are currently pending for calculations of past due disability benefits, interest, and attorney fees. A copy of the court’s opinion is available upon request.

At the time of filing for disability our client was working in Honolulu for Hilton Vacation International selling timeshares. Our client, a 47 year-old woman was at the prime of her sales professional career when she gave up her job due to chronic neck pain. Her pre-disability income and was in excess of $320,000. The time-share and real estate market was booming in mid 2004 when she was forced to stop working. Our client worked more than 60 hours per a week and was paid pure commission. As an employee benefit our client paid a monthly premium for a long-term disability policy that would pay her 60% of her monthly income each month if she became unable to perform the substantial and material duties of her occupation as a vacation sale professional. Prior to filing for disability, our client had been continuously treating with a Rehabilitation and Medicine doctor in order to help manage her pain. Additionally, she had undergone multiple cervical injections, was taking pain killers daily, missed multiple days from work, and attempted to reduce her hours in order to keep her job. Our client has seen more than 8 different doctors (orthopedics, neurosurgeons, physiatrist, and anesthesiologist) and has been recommended for neck surgery by 3 different doctors. All of these doctors support her inability to work due to chronic neck pain.

Prudential initially denied the claim on January 25, 2005 and relied on a paper review by one of their consulting doctors, who claimed that if she used a phone headset and an ergonomic chair to do her job she would have no problems. This Dr. never examined or spoke with our client. Our research revealed that Prudential paid this doctor more than $130,000 in 2005 and Prudential has a long-standing relationship with this doctor who practices at a medical school next to Prudential's NJ headquarters. On July 28, 2005 our firm submitted a 65 page single spaced appeal of the denial to Prudential with additional support for our client's claim. During the review of the first appeal, which was suppose to be completed in 45 days according to ERISA law, Prudential decided they wanted to have a doctor of their choice examine our client. This exam took place, December 16, 2005, which was now more than 1.5 years after our client’s claimed date of disability. We requested to video the exam of our client, as we usually do, and the Dr. hired by Prudential refused. The exam took place, and the doctor found that our client has objective evidence of a cervical degenerative condition; however it should not prevent her from doing any job. The doctor was suppose to determine if her medical condition would prevent her from doing her substantial and material duties as a vacation sales person, but he went as far as to say she had no restrictions preventing her from doing any job. While Prudential would not allow the video of the exam, Prudential hired a private investigation company to follow our client around with a video camera for 7 days. The first two days of video surveillance were the day before and the day of the exam with Prudential's hired doctor. The remaining days were within the following two weeks. Prudential paid $9,439.00 to the video surveillance investigators. Over 7 days, the investigators produced a total of 30 minutes of tape, of which more than 20 minutes was our clients visit to the beach on New Years Eve day with her family.

On February 13, 2006 Prudential entered their second denial and relied on the exam by the doctor they hired (paid him $5,000) and their own internal doctor’s report. On August 21, 2006, Attorneys Dell & Schaefer submitted a 100 page single spaced appeal letter to Prudential with additional information. ERISA law requires a policy holder to submit appeals and exhaust administrative remedies before the insured is allowed to file a lawsuit in Federal Court. Additionally, ERISA provides that an insured shall receive a full and fair review at each level of the appeal. The idea is that the Insurance Company will have different people review the claim at each level of the appeal. Unfortunately for our client, when she submitted her final appeal it was denied by the same Prudential Vice-President that made the decision to deny her first appeal submitted on July 28, 2005. Prudential treats large monthly benefits different than other claims and has a policy that any monthly benefit in excess of $10,000 must be approved by a Director or Vice President. The second and final appeal was denied on December 5, 2006 and Prudential relied on the video surveillance of our client at the beach on December 31, 2005 as the basis of their denial. Furthermore Prudential sent the video to the doctor they hired and he said that the video shows that our client could work for only as long as she seems to be functioning on the video. Keep in mind the video was 30 minutes long and our client worked a 60 hour week. Additionally, the video shows our client swimming for a total of 2 minutes and 30 second, and Prudential felt that if she could swim, then she can perform the duties of her 60 hour work week. In the July 2009 opinion, the court held that the video surveillance of our client was not representative of her ability to work as she had advised Prudential that she would like to go to beach on the weekends with her husband.

Following the second and final appeal denial a lawsuit was filed in Federal Court and Prudential has continued to fight the case every step of the way. Prudential denied our request to take depositions of 8 prudential company representatives and after an extensive motion the Judge granted the request. The depositions were taken and the information obtained was extremely helpful in presenting our client’s case at trial. Some individuals deposed at Prudential were the Vice President of Long-Term Disability, Director of Group Disability and Director of the Appeals Unit. During the pending lawsuit, Prudential challenged the standard of review to be used by the court claiming that the court did not have the discretion to review the entire Administrative Record and make a determination if our client is disabled. Prudential argued that that the disability policy granted them "discretion" and asked the court to apply an arbitrary and capricious standard, which means the court can only reverse the claim denial if the court finds that Prudential acted unreasonable. Our firm filed a motion to clarify the standard of review, which Prudential opposed, and the court agreed with our Client that Prudential does not have discretionary authority and the court must review the entire record De Novo.

Prior to Trial on May 19, extensive Trial and Reply Trial Briefs were filed with the court on behalf of our client. Prudential filed a motion recently claiming that ERISA does not allow our client to call live Dr. Testimony at trial. In accordance with ERISA, The judge granted Prudential's motion and said that the medical issues in this case do not rise to the level of complexity which requires additional medical testimony. ERISA law is very restrictive and does not provide a claimant with the right to a jury trial, therefore this case was decided by a Judge only.

Prudential will likely appeal and this case may go on for another 1.5 years. Currently she is owed disability benefits from November 6, 2004, in excess of $900,000 at a monthly benefit amount of approximately $16,000. Our client has been unable to work since the date of her accident. The attorney fees accrued to date are in excess of $500,000 and more than 1,000 hours of legal time have been spent on this case. The court has the discretion to award attorney fees if our client wins at trial. Our client is entitled to benefits until age 65 if she is disabled under the terms of the disability policy. After 2 years of disability the definition of disability changes to unable to perform any occupation that pays 60% of pre-indexed disability earnings within 12 months of her return to work. As of right now that would mean a job that pays our client $228,000. The total value, of our client’s policy, including benefits to age 65 is approximately 3 million dollars. ERISA does not allow punitive or bad faith damages against prudential for their wrongful denial of benefits.

Prudential has nothing to loose by denying our client's claim for long-term disability benefits, because if they are proved wrong, they end up having to pay what they should have paid 4.5 years ago. Prudential is able to hide behind the protections of ERISA, find a doctor to say our client can work, and then see if a court will make them pay a claim 5 years latter. In the meantime Prudential delays payment until the Appellate court tells them they must pay. Along the way, Prudential may make a low-ball offer after they have backed the claimant into a financial hole that leaves the claimant without the ability to fight anymore. All though our client won her case, the public should continue to be aware of the unreasonableness of ERISA law and the way in which companies such as Prudential manipulate the system to their advantage. The unreasonable actions of large disability insurance companies where they place their profits before the well being of those that bought disability contracts to protect themselves shall not be tolerated.

Attorneys Dell & Schaefer handle long term disability claims throughout the country and currently represent more than 200 hundred claimants against every major long-term disability insurance company. We have lawsuits pending against multiple disability carriers in multiple states. We welcome the opportunity to provide a free consultation regarding any long-term disability insurance claim.
 

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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.
 

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Our client, who suffers from Parkinson’s, was a highly skilled engineer and operations manager for an international corporation before his illness rendered him unable to perform the duties of his occupation. Diagnosed with Parkinson’s years before filing for long term disability benefits under his company’s disability plan, he did everything in his power to work at a job he enjoyed and excelled at. However, the nature of his illness began to take a heavy toll, as symptoms relating to his cognitive functioning began to worsen. Left with little choice, he applied for disability benefits under his company’s short term disability policy in March of 2008. He was approved for short term benefits under the disability policy. However, in October of 2008, when the short term disability benefits were exhausted, MetLife denied his claim for long term disability benefits.

He then contacted Attorneys Dell and Schaefer to appeal MetLife’s denial. From the start, MetLife was uncooperative in requests for information made by Dell and Schaefer. Persistent in our representation we finally secured all of the documentation requested. Review of the MetLife claim file immediately identified how MetLife wrongfully denied our client’s claim. The most glaring injustice was that in denying his claim, MetLife relied upon the opinion of a licensed social worker and a registered nurse. MetLife had a duty to our client to give his claim for long term disability income benefits a full and fair review, and failed to do so when they decided to not hire appropriately qualified medical providers in the area of Parkinson’s to render opinions as to our client’s functional capabilities. In addition to this, the individual’s hired by MetLife to review our client’s medical records did not contact our client’s treating physicians to gain any insight into his condition, nor did they draft any reports documenting their findings and opinions. Moreover, MetLife relied on the report of a vocational rehabilitation specialist, who completely failed to identify the duties of our client’s occupation. Instead, the specialist concentrated on the most insignificant of job duties in rendering her opinion our client could perform his occupation.

Attorney’s Dell and Schaefer helped to guide our client to proper treating physicians for his condition, as well as tests to be performed that would counter MetLife’s reasons for denying his claims for long term disability benefits. To develop a better understanding of our client’s pre-disability occupational duties and his difficulty performing those duties, Dell and Schaefer contacted past co-workers for further insight, and to help present a complete picture of the battle our client endured with Parkinson’s. Armed with objective testing to prove cognitive dysfunctions and an understanding of the true nature of our client’s occupation, Dell and Schaefer filed an extensive appeal with MetLife to overturn the wrongful denial of long-term disability benefits. MetLife had 45 days under ERISA in which to review the appeal, however, presented with overwhelming evidence and arguments as to the mishandling of the claim, MetLife overturned its denial in less than one month.

This case was handled by attorneys Gregory Dell and Stephen Jessup.
 

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