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

Mrs. Kaufmann was employed as a senior project manager by Siemens Corporation. Mrs. Kaufmann was a member of the long term disability plan through MetLife who was both the administrator and payor of disability benefits. On May 26, 2006, Mrs. Kaufmann stopped working on advice from her treating physician, Dr. Daniel T. Rubino. Because of an unsuccessful diskectomy and laminectomy, Mrs. Kaufman suffered from severe chronic pain. Mrs. Kaufman suffered from progressive back pain, disc protrusion and herniation, stenosis and radiculopathy which led her to seek help from those unsuccessful surgeries.

MetLife initially paid disability benefits, but then terminated them on November 9, 2007, claiming that Mrs. Kaufmann had failed to provide evidence that she was unable to perform the duties of her occupation. Mrs. Kaufmann claimed that the basis for the denial was that Met Life mischaracterized her ‘light duty job’ as a ‘sedentary’ job. On February 4, 2008, Dr. Rubino completed a narrative report stating that his patient “cannot sit or stand for longer than 15 minutes without changing positions due to chronic pain impulses. She has severely decreased concentration ability, preventing her from having gainful employment, not to mention her physical limitations.” He also added that “as of August 21, 2007, Nancy was no longer able to perform her pre-injury job with Siemens Corporation on a full-time sustained basis.”

Prior to her care with Dr. Rubino, Mrs. Kaufmann had multiple diagnostic tests and exams which confirmed her spinal pain. Her orthopedic surgeon, Dr. Richard Balderston, stated that surgery would most likely make her situation worse and that the best treatment she could receive would be pain management. The same opinion was had by Dr. Howard Richter, a neurosurgeon who also commented on her “chronic and worsening left leg pain of uncertain origin.”

Met Life referred the case to Dr. Frank Nisenfeld, who reviewed only records with no examination of Mrs. Kaufmann. After a review of Mrs. Kaufman’s medical records, Dr. Nisenfeld concluded that the treating physicians were correct and that the condition would not improve, including his statements that there were ‘no surgical or medical answers.’ He concluded that medications would most likely cause functional impairment as well as safety risks. Still, because of Met Life’s classification of Kaufmann’s job as sedentary, he opined that Mrs. Kaufman’s medical problems should not prevent her from performing sedentary work.

When Metlife terminated disability benefits in November of 2007, the letter stated, “Based on the findings of the review, there was no medical documentation to support an ongoing functional impairment that would limit your ability to perform your sedentary occupation.”

After this denial, Dr. Rubino sent Mrs. Kaufmann to Dr. Wendy Wang, who did a comprehensive and thorough functional capacity evaluation on December 12, 2007. Dr. Wang took into account each of Kaufmann’s job duties and whether or not they would be affected by her illnesses. She concluded that as a product manager, Mrs. Kaufmann was required to travel by plane or car at least once a week, with a suitcase weighing more than 30 lbs that she must be able to perform prolonged walking, sitting, driving, pulling, lifting and more. Dr. Wang concluded that Mrs. Kaufmann was unable to perform these duties, or to live up to the mental component required by the job.

The case was then referred by Met Life to Dr. Ephraim Brenman, who conducted a review and found that Kaufman was “not precluded from working full time in any capacity,” and “is able to work full time, at least a sedentary level of duty.” Kaufmann’s doctor, Dr. Rubino, commented on Dr. Brenman’s findings, stating that there were subjective complaints, documented by objective findings in the medical reports and that "even if there were none [objective findings], this does not preclude her from having these problems."

On April of 2008, Met Life informed Mrs. Kaufmann that they were upholding their decision to terminate disability benefits based on the report from Dr. Brenman. Several things must be considered here. Although Dr. Nisenfeld agreed with Dr. Rubino on certain points, he said that Kaufmann should be able to perform her job. However, Dr. Nisenfeld was never given a job description of Kaufmann’s occupational duties, and never examined her personally. Met Life’s experts never looked thoroughly at Dr. Wang’s report and never offered anything up to suggest that Dr. Wang’s report was wrong or that the details could be interpreted differently. Dr. Brenman never even considered or commented on the situation at hand he only gave a vague analysis to the situation without knowing what Kaufmann’s work duties were.

Kaufman filed a lawsuit in federal court and the court found in favor of Kaufmann on the basis that Met Life’s decision to deny benefits was not supported by substantial evidence and in fact, it was arbitrary and capricious.

*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.
 

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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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Disability Insurance Policies are complicated legal documents that are unfortunately difficult for most individuals to properly understand. While a disability policy is intended to be drafted so that a claimant will clearly understand all of the terms and conditions, a claimant’s misunderstanding can jeopardize a claimant’s right to disability benefits. A recent disability case reveals the importance of complying with a disability policy’s statute of limitations provisions. A statute of limitations is the period of time in which a lawsuit may be filed. Failure to file a lawsuit within the statue of limitations will result in dismissal of a lawsuit. The steps that must be taken in order to obtain disability benefits are not always contained within the disability policy.

Scharff vs Raytheon Company

Donna Scharff was an employee of the Raytheon Company, as well as a participant in both their short-term and long-term disability benefit plans. The plans, privately funded by the Raytheon Company, were administered by MetLife. When Scharff applied for short-term disability benefits and was denied, internal appeals took place before Raytheon gave Scharff their final decision  including a statement to refer to the summary plan description for more information on how to file a lawsuit.

The summary plan description (or SPD) had been provided to each employee involved with the plan and included statute of limitation information in the ‘Disability’ section under ‘Claims Appeal Procedure.’ When Scharff received her letter of denial, the administrator of the plan did not specifically say to check the statute of limitations provided in the SPD.

Mrs. Scharff filed suit against Raytheon Company, with the goal of receiving both her short term and long term disability benefits. However, the Raytheon Company stated that Mrs. Scharff’s lawsuit was untimely and moved to dismiss the case, as the ‘one year’ statute of limitations had already passed by 20 days. Mrs. Scharff said that her untimely filing should be excused, as she was not aware of the statute of limitations  and that the company failed to point it out to her in the denial letter.

The District Court disagreed with Mrs. Scharff and dismissed her case, because of the fact that Scharff filed her lawsuit 20 days after the one year statute of limitations.

Appeals

Mrs. Scharff appealed the decision made by the District Court, and the appellate court felt as if MetLife did not have a duty to inform her of the statute of limitations in their denial letter. The appellate court also felt as if the information in the SPD was fine where it was, because most individuals would not have trouble finding that information.

The appellate court stated, “A reasonable plan participant whose disability claim had been denied would proceed, naturally, to examine the information that appears under the large-typeface, bolded, and italicized heading, ‘Claims Appeal Procedure’… the average participant in the Plaintiff’s position would have located and understood the one year deadline in the SPD.”

The court ruled that:

- The placement of the one year statute of limitations information in the SPD was not intentionally deceptive and that most individuals would have found and understood it.
 

- The placement of the one year statute of limitations did not violate guidelines set forth by ERISA or other laws regarding the clarity of contracts.

Mrs. Scharff’s lawsuit would not have been dismissed had she seen and understood the statute of limitations however, this is another example of how easy it is to misunderstand the language of disability insurance policies.

*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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Our client, a Senior Sales Manager for a large medical supply company, was suffering from severe spinal stenosis and an injury to her ulnar nerve following an epidural steroid injection. As a result of these disabling conditions, our client suffered from a multitude of physical problems, which included: loss of range of motion in the neck and shoulders; loss of grip strength of the left hand; numbness, tingling, and burning of the left forearm, extreme sensitivity to cold temperatures or light touch, and constant pain. The only way to provide some relief to the constant pain was through prescription pain killers, which left our client groggy and unable to focus or concentrate fully.

 As a Senior Sales Manager, our client’s occupation required meticulous attention to detail, the analysis of complex data and the ability to effectively present informational findings in order to increase revenue for the company. Our client was responsible for directing the development of the business and marketing strategies for a division of her company that was worth in the hundreds of millions of dollars.

 While on short term disability, our client contacted our office as a result of the nonstop barrage of information requests and deadlines from MetLife regarding long term disability benefits. Forms sent from MetLife appeared at first glance to be redundant, but just different enough to cause our client concern that MetLife’s intention may be finding a way to deny long term disability benefits. The same day Attorneys Dell & Schaefer was retained to represent our client in her application for long term disability income benefits, we contacted MetLife to notify them of our representation, and to request that all written and oral communications are handled exclusively through our office.

 We immediately obtained all of the application materials, and began to collect and request all the information pertinent to ensuring our client’s claim would be approved the first time. Working closely with our client, Attorneys Dell and Schaefer, submitted a thorough, twenty-six page application packet to MetLife that was in far greater detail and depth than the initial 6 page application MetLife sent. By gaining a detailed knowledge of our client’s occupational duties, day to day schedule, and a thorough understanding of our client’s medical condition, combined with our knowledge and experience in dealing with disability insurance companies, Dell and Schaefer was in a much better position to preempt any arguments or additional requests for information MetLife might make under the terms and conditions of the policy.

MetLife approved our client’s claim for long term disability income and Dell & Schaefer will continue to handle all issues of her disability claim on monthly basis.

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