Beneficiaries of disability insurance policies are seldom faced with an easy task when trying to claim disability benefits. Usually there are a long list of procedures with which claimants must follow before disability insurance companies approve their claim for disability benefits. Hence, it is advisable to have a disability attorney handle your claim for disability benefits at the very onset of your claim to ensure that your claim is handled properly. The case of Elizabeth Bailey as Administrator for the Estate of Adrian Douglas Bailey. Jr vs. Fortis Benefits Insurance Company (Fortis) is an example of why it is a prudent to have a disability attorney to represent you from the beginning of the claim process. Our law firm did not handle this disability lawsuit, however it is extremely strange why this case took more than 10 years to litigate.
The Alleged Facts Of The Case Against Fortis
The deceased participated in a Group Short Term Disability Insurance plan and an Accidental Death and Dismemberment Insurance Plan that was issued by Fortis. Due to severe depression, the deceased stopped working and applied for short term disability benefits. Fortis approved the deceased’s claim for short term disability benefits on January 24th 1997.
During the interim period leading up to the suspension of the deceased’s short term disability benefits by Fortis on June 6th 1997, the deceased was being treated by his attending psychiatrist. The deceased’s attending psychiatrist noted that the deceased was making some recovery and also that "he wanted to stay at home [with his children] rather than returning to work."
Termination of Disability Benefits
Following the phone consultation by Fortis with the deceased attending psychiatrist on June 3rd 1997, Fortis suspended the deceased’s short term disability benefits pending a review by the in-house Clinical Service Department. Following the review, it was concluded by Fortis’s in-house psychiatrist that the deceased was no longer disabled. Hence, on August 4th 1997, following the completion of its review of the deceased’s claim, Fortis terminated the deceased’s short term disability benefits.
On September 17th 1997, the deceased’s wife filed a complaint with the West Virginia Office of the Insurance Commission complaining of Fortis’s decision to terminate the deceased’s short term disability benefits. Fortis regarded this complaint as an appeal then invited the deceased to submit additional information and medical records to support this appeal.
On March 12th 1998, Fortis reaffirmed its previous decision to deny the deceased his claim for disability benefits. Fortis reasoning was that the deceased was originally cleared to work for a few months before his condition took a turn for the worse. Another complaint was filed by the deceased on October 27th 1998 with the West Virginia Office of the Insurance Commission when the deceased learnt that he was awarded Social Security Benefits(September 1998).
Again, Fortis regarded this complaint as an appeal by the deceased. However, while the appeal was being considered, the deceased passed away due to an unrelated medical condition. Just before the deceased passed away, he filed a claim for long term disability benefits and was informed that such benefits were not available while the appeal for short term disability benefits was pending. Upon the deceased demise, the plaintiff Mrs Bailey, the deceased’s wife, filed a claim for life insurance benefits under the deceased’s Accidental Death and Dismemberment Insurance Plan.
The Lawsuit Against Fortis
In September 2001, the plaintiff Mrs Bailey filed an ERISA lawsuit against Fortis seeking an award short term disability benefits, long term disability benefits and life insurance benefits on behalf for the estate of the deceased.
The Opinions of the District Court
The District Court in this case denied the plaintiff’s motion for Summary Judgment but granted Fortis motion for Summary Judgment. There were two main issues for the Court to decide. One issue was the claim for short term disability benefits and the second issue was the claim for long term disability benefits together with the life insurance benefits.
The Short Term Disability Benefits
The Court reasoned that it is the burden of the plaintiff to submit satisfactory proof of his disability. The medical opinions relied upon by the deceased was insufficient to prove the deceased’s disability status while on the other hand, there was evidence on record to show that the deceased was able to return to work as early as May 22nd 1997. In addition, the plaintiff’s reliance on the Social Security Administration (SSA) determination of disability provided no basis for concluding that the deceased was disabled under the plan as the plaintiff failed to show that the Plan used a similar definition of disability as the SSA.
The Long Term Disability Benefits and Life Insurance benefits
According to Fortis, the plaintiff never filed a formal claim for long term disability benefits and life insurance benefits. As such, the plaintiff failed to exhaust all the administrative remedies before bringing the case to the Federal Court for judicial review. The Court ruled that the plaintiff’s affidavit attesting that she applied verbally for these benefits was problematic as the affidavit was not part of the administrative record. Hence, the affidavit cannot be considered in the judicial review process. Furthermore, even if accepted, the Court stated that it only goes to show that the plaintiff did not apply properly for the above mentioned benefits as required under the terms of the Plan and hence left no factual record to assist the Court in reviewing the plaintiff’s claim.
About the author: Gregory Michael Dell is an attorney and managing partner of the disability income division of Attorneys Dell & Schaefer. Mr. Dell and his team of lawyers have assisted thousands of long-term disability claimants with their claims against every major disability insurance company. To request a free legal consultation call 800-411-9085.