Never ignore a 180 day ERISA Appeal deadline or it is likely you will never have an opportunity to present your disability insurance claim denial in court. Continue Reading Missouri Court Holds no Claim for Disability Insurance Benefits Allowed Past 180 Day Deadline
The Connecticut Plaintiff, Heimeshoff, filed an ERISA lawsuit against Hartford challenging their denial of long-term disability benefits. Hartford filed a Motion to Dismiss as Heimeshoff filed her lawsuit past the 3-year statute of limitations which was clearly stated in her policy. The District Court granted Hartford’s Motion to Dismiss and Heimeshoff appealed.
The diagnosis of fibromyalgia is made purely on clinical findings based on the history obtained from the patient and the doctor’s physical examination. There are no objective tests that specifically point the doctor to the diagnosis of fibromyalgia. However, there are several tests that can be done to exclude other possible diagnoses.
The National Health Institute explains that, in patients with chronic widespread body pain, the diagnosis of fibromyalgia can be made by identifying point tenderness areas (typically, but not always, patients will have at least 11 of the 18 classic fibromyalgia tender points), by finding no accompanying tissue swelling or inflammation, and by excluding other medical conditions that can mimic fibromyalgia.
Fibromyalgia patients have widespread body pain which often seems to arise in the muscles. Although many fibromyalgia patients are aware of pain while they are resting, it is most noticeable when they use their muscles. Their discomfort can be so severe it may significantly limit their ability to lead a full life. Patients can find themselves unable to work in their chosen professions and may have difficulty performing their everyday tasks. Most fibromyalgia patients learn quickly there are certain things they do on a daily basis that seem to make their pain problems worse. These actions usually involve the repetitive use of muscles or prolonged tensing of a muscle, such as muscles on the upper back while looking at a computer screen.
Courts Address Problems Producing Objective Evidence in Fibromyalgia Cases
A common reason for the denial of disability benefits when a claimant is diagnosed with fibromyalgia or chronic fatigue syndrome is the failure to provide objective medical evidence of these disorders. Some policies specifically require objective proof of illness. This policy language becomes problematic when disabling conditions such as chronic fatigue syndrome and fibromyalgia cannot be proven by blood tests, x-rays or CT scans.
The First and Second Circuit Courts have addressed this very issue, recognizing that the causes of Fibromyalgia are unknown, that there is no cure and, of greatest importance, its symptoms are entirely subjective. In the case of Cook v. Liberty Life Assurance Company, the court held that "since there are no specific laboratory findings that are widely accepted as being associated with CFS, and given the nature of Cook’s disease, it was not reasonable for Liberty to expect her to provide convincing ‘clinical objective’ evidence that she was suffering from CFS."
Courts do recognize, however, that there are physical limitations imposed by the symptoms of theses illness that do lend themselves to objective analysis. As a result, Fibromyalgia can be diagnosed, more or less objectively, by the 18-points test that can be performed by a rheumatologist or primary care physician.
Failure to Undergo 18 Point Tender Point Test Can Result in a Disability Denial
It is very important to treat with a physician that is experienced in the diagnosis and treatment of fibromyalgia, such as a rheumatologist or your primary care physician if he or she has experience with this disease. A primary care physician may suspect that you have fibromyalgia, but may not be familiar with the signs and symptoms and the way in which to confirm the diagnosis.
Hartford Insurance Disability Denial Upheld By Court of Appeals
On January 24, 2013, the Second Circuit Court of Appeals addressed this very issue in the case of Ianniello v. Hartford Life and Accident Insurance Company. In this case, the Plaintiff, Virginia Ianniello, was suffering from chronic fatigue and fibromyalgia and, as a result, could not perform the material duties of her occupation. Hartford denied her claim on the basis that she failed to undergo the tender points test. The Plaintiff argued that it was unreasonable for Hartford to require her to undergo such testing since her policy does not require it and she was not asked specifically to provide it. Furthermore, she argued that no objective test for fibromyalgia has been generally recognized by the medical community. The Court held that "although the terms of the policy did not require objective evidence of disability, it was not unreasonable for a plan administrator to require tender points testing so long as the claimant was notified." The records showed that the Plaintiff was well aware of the use of the tender points as a diagnostic criterion for fibromyalgia, and had the opportunity to obtain and present such testing results to Hartford. Because the Plaintiff bore the burden of showing that she was disabled, Hartford’s demand for objective evidence was neither arbitrary nor capricious.
Ms. Ianneillo’s failure to undergo a tender points examination cost her the long-term disability benefits she would have been entitled to collect had she provided such evidence. This is why it is extremely important for you and your treating physicians to understand the terms and conditions spelled out in your policy and to pay attention to the reasons for the initial denial. It is also important to ensure that you treat with the proper physician who specializes in the very disease or illness that prevents you from working. This case was not handled by our law firm, but with proper guidance prior to any claim denial, this seems like a claim denial that could have easily been avoided.
If your claim for short or long term disability benefits has been denied, please contact Attorneys Dell & Schaefer for a free consultation.
The case of Reindl v. Hartford Life and Accident Insurance Company is one example of what can occur if you fail to file a timely appeal. Our law firm did not handle this disability lawsuit, but we have blogged about it so that this situation does not happen to anybody with a Hartford disability claim. The Plaintiff, Ms. Reindl participated in an employee welfare benefit plan administered by Hartford during her employment with RKM Enterprises. She stopped working in 2005 and applied for disability benefits which were approved. In 2008, Hartford sent her a letter terminating her benefits claiming that she was able to work and gave her 180 days to file an appeal. Ms. Reindl hired an attorney to file the appeal for her. In December of 2008, her attorney sent a letter to Hartford requesting her claim file and medical records, but failed to file the appeal prior to the 180 day deadline. Hartford did not accept the appeal stating that it was received after the 180 days had expired. Plaintiff’s attorney claimed that the letter he sent in December of 2008 requesting records should be considered the appeal. Hartford disagreed.
A Mere Request for Records Is Not Considered an Erisa Appeal
Ms. Reindl filed a lawsuit against Hartford challenging termination of their long-term disability benefits. The District Court Judge in Missouri granted Hartford’s Motion for Summary Judgment on the basis that Plaintiff’s attorney failed to file a timely appeal and the letter sent by Plaintiff’s attorney requesting records was not considered an appeal. Plaintiff appealed the decision to the 8th Circuit Court of Appeals. The Court upheld the lower court’s decision holding that a timely administrative appeal is a prerequisite to filing an action in federal court challenging the denial of benefits under a plan governed by ERISA. The Court concluded that Hartford’s determination regarding the December 2008 letter was reasonable, as a request for records is not an appeal. Therefore, the decision of the lower court was affirmed and Plaintiff cause of action was dismissed with prejudice.
How Can You Prevent This Very Situation From Happening to You?
The best solution is to make sure to contact an experienced ERISA attorney as soon as you receive your denial letter. This way you can ensure that your attorney has ample time to investigate and build up your claim in order to put together an elaborate appeal in a timely manner. The failure to exhaust your administrative remedies will prevent you from being able to bring suit in a court of law. Once this mistake is made, it cannot be corrected. You can find helpful information about ERISA Appeals by visiting this page.
For ten years our client was receiving long term disability benefits from CIGNA under an ERISA governed Group Disability Policy (Jaycor) due to a litany of medical conditions, which included Adult Onset Still’s Disease, Chronic Pain, Fibromyalgia and Fatigue. During the course of his claim and well prior to CIGNA’s termination of benefits, he had already met and passed the own occupation to any occupation definition change, had been approved for disability benefits by the Social Security Administration, and had even been approached by CIGNA on several occasions for a lump sum buy out of his policy. For all intensive purposes it would seem that at the age of 60 and the decade long history of his claim that CIGNA would not challenge the claim. However, CIGNA proved the adage that disability benefits are never guaranteed benefits.
Disability Blog & Cases:
California Court orders CIGNA to disclose amount paid to MES Solutions for medical reviews
CIGNA Insurance Company can run but they can’t hide. Recently, the US District Court for the Central District of California granted Plaintiff Bradley Wojno’s Motion to Compel Defendant CIGNA Insurance to reveal the extent of it financial relationship with MES Solutions. Mr. Wojno’s California disability attorney sought information from CIGNA that could unveil potential conflicts and biases of CIGNA’s hired gun doctors relied upon to terminate Mr. Wojno’s disability benefits.
Disability claimants need to be extremely cautious when dealing with Sedgwick Claims Management Service Inc. (Sedgwick). From our law firms’ experience of handling thousands of disability insurance claims, Sedgwick is one of the top three most difficult companies to deal with. Unfortunately, Sedgwick will capitalize on any opportunity to deny a claimant their disability benefits. This case discusses the unreasonable conduct used by Sedgwick to wrongfully deny disability benefits.
Disability claimant challenges Standard Insurance Company’s attempt to limit disability benefits to 24 months under the “Other Limited Conditions” provision.
LINA should be embarrassed and show some respect for a former payroll clerk that had no ability to work due to numerous medical conditions. After litigating for more 4.5 years since her wrongful denial of disability benefits, Ms. Dupree finally received a ruling in her favor from the United States Court of Appeal. LINA fought this disability claim until there were no more courts left for them to appeal to. While, Ms. Dupree eventually won her disability benefits, it is sad that she had to battle for 4.5 years without any payment from LINA. LINA essentially left Ms. Dupree out in the cold. Unfortunately, Dupree’s only remedy is payment of her benefits, interest and attorney fees. This case is a prime example of the wrongful conduct by LINA and the exact reason that punitive damages should be allowed.
In Mary Carten vs. Hartford Life and Accident Insurance Company, Group Long Term Disability Plan for Employees Of FMR Corporation, the plaintiff brought the civil lawsuit in a California Federal Court under the Employment Retirement Income Security Act (ERISA) to challenge a denial of disability benefits made by the Hartford Life and Accident Insurance Company (Harford). The plaintiff requested an opportunity to conduct discovery into Hartford’s claims handling practices in order to determine if Hartford’s wrongful denial her long term disability benefits was done with a conflict of interest. It is ironic that Harford denies disability benefits and then tries to do whatever they can to hide the existence of their financial relationship with the doctors they hire. Hartford is suppose to be the fiduciary of Ms. Carten. Hartford’s actions clearly suggest that they are not acting in the best interest of Ms. Carten.
In the case of D. Nielsen Pollock Vs Standard Insurance Company, filed at the District Court for the Southern District Of California, the plaintiff complained that the Standard Insurance Company (Standard Insurance) have breached the Employee Retirement Income And Security Act Of 1974 (ERISA) and suing for the recovery of disability benefits under the terms of an employee benefit plan for which Standard Life is the insurer of benefits under the “DILLINGHAM CONSTRUCTION HOLDINGS INC. GROUP LONG TERM DISABILITY INSURANCE POLICY.”
When making a case for a claim of disability benefits, it is essential that a claimant has strong medical support from treating physicians. The disability insurance companies are not under any duty to help a claimant further his or her claim for disability benefits. It is the burden of the claimant to ensure that he or she had provided sufficient proof of his or her disability status. This case of Almetta T. Campbell Vs. Hartford Life And Accident Insurance Company is a good example of how a disability insurance company can easily win a disability denial if the administrative record does not have strong medical support. Disability claimants must anticipate and be prepared for a change of the policies definition of disability from own occupation to any occupation. ERISA governed policies can make it difficult for disability claimants to prevail.
In the case of Gwendolyn Byrd vs. UNUM Life Insurance Company Of America, the plaintiff filed a lawsuit in Texas federal court to challenge the Unum Life Insurance Company’s (Unum) decision to terminate her long term disability benefits after paying for 5 years. In the review for the abuse of discretion, the District Court granted summary judgment to Unum. The plaintiff is appealing this decision by the District court.
After 5 years of receiving long term disability benefits, Robin Dolan suddenly receives a letter in 2006 from Disability Reinsurance Management Services stating that her disability benefits had been wrongfully calculated and she must repay $163,661.57. Approximately 5 years after receiving this dreadful letter and extensive litigation, Ms. Dolan has finally received an Appellate Court ruling stating that Liberty Mutual was wrong in their interpretation of the disability policy. Unfortunately Ms. Dolan has had to suffer through the unreasonable actions of Liberty Mutual and their third party administrator DRMS.
A New Jersey disability attorney recently instituted a lawsuit against the UNUM Life Insurance Company of America (UNUM) at the District Court for the District of New Jersey of behalf of a disabled client. In Robert Garozzo v UNUM Life Insurance Company of America and RTP Technology Corporation long term disability plan, the plaintiff Robert Garozzo is seeking payment of disability income benefits from UNUM under the terms of a long term disability Benefit plan.
For a disability insurance contract, one of the most important clauses in the contract will be the “own occupation” definition of what constitutes disability. The implication of this clause is that if you become “disabled” due to sickness or injury and are unable to work in your specific line of work, the insurance policy will pay you disability benefits even if you decide to work in another line of employment.
Florida Disability Lawyer Sues Sedgwick Claim Management Services
In the case of Richard Shane Burnett Vs Sedgwick Claim Management Services, Inc. D/B/A AT&T Integrated Disability Service Center, filed at the District Court for the Middle District of Florida, the plaintiff Richard Shane Burnett alleged that he is eligible for short term disability (STD) benefits under an employee benefit plan provided by his employer.
Colorado disability lawyer files lawsuit against Unum Life Insurance Company Of America for denying long term disability benefits and wrongfully asserting no objective test exist to diagnose fibromyalgia
In Kelly Ann Curtis vs Unum Life Insurance Company of America, a Colorado disability attorney filed a lawsuit on behalf of a disability claimant against the Unum Life Insurance Company of America (Unum) at Denver County District Court. The case is quite interesting as it illustrates how disability insurance companies can, by applying certain limiting clauses in disability insurance contracts, avoid paying out disability benefits to the insured.
Disability Blog & Cases:
Fifth Circuit Court Of Appeal denied Estate Of Pepsiamericas, Inc.’s employee motion to recover accidental death and dismemberment benefits from group disability insurance plan issued by Unum
Recently the Court of Appeal Fifth circuit rendered their opinion in the case of Mary Ann LETTER, Individually and as Executrix Administratrix of the Estate of Timothy D. Letter vs. UNUM PROVIDENT CORPORATION; Unum Life Insurance Company of America. They ruled that the plaintiff Mary Ann Letter, individually and as acting as the estate of her husband Timothy D. Letter was not entitled to recover Accidental Death And Dismemberment (AD & D) benefits from her deceased husband’s group insurance plan due to non payment of premium.
A Washington disability attorney recently filed a lawsuit on behalf of his client at the District Court for the Eastern District of Washington against the Hartford Insurance Company (Hartford). In the case of Robin (Hunt) Hankel v The Hartford Insurance Company /The Hartford Financial services Group, the plaintiff was a woman employed in the health Safety and Environmental Management/ Engineering field for Harpers. While employed with Harpers, she contributed to a disability insurance plan which was issued by Hartford.
Recently, a former account clerk of the Katz Insurance Group filed a lawsuit against the Fort Dearborn Life Insurance Company (Fort Dearborn Life) through a Maryland disability attorney at the District Court for the District of Maryland. In the case of Tosha Pederson v Fort Dearborn Life Insurance Company, the plaintiff alleged that Fort Dearborn Life had acted arbitrarily and capriciously in its decision to deny the plaintiff’s claim for long term disability (LTD) benefits.
The Northwestern Mutual Life Insurance Company (Northwestern Life) was recently sued by a Washington disability lawyer for the violations of the Washington Insurance Fair Conduct Act and Washington Consumer Protection laws. In Kurt D. Bennett v The Northwestern Mutual Life Insurance Company, the plaintiff alleged that Northwestern Life in denying the plaintiff’s claims for disability benefits was in violation of the above mentioned laws and breached the terms of the disability insurance policy.
Recently a California disability attorney filed a lawsuit against the Liberty Life Assurance Company of Boston (Liberty Life) at the Superior Court of the state of California. In the case of Cassie Ray v Liberty Life Assurance Company of Boston, the plaintiff alleged that by denying the plaintiff’s claim for disability benefits, Liberty Life, among other things, had caused the plaintiff to suffer damages. This disability policy is not governed by ERISA as the claimant is a government employee.
Disability Insurance Law TV:
A Senator’s view of ERISA disability insurance claims
This video features the testimony of Montana United States Senator Max Baucus at a Senate Finance Committee Meeting. Senator Baucus focuses his testimony on the problems with ERISA disability insurance laws and the unfair claims handling practices of disability insurance companies. Senator Baucus pays specific attention to two long term disability insurance claims that were wrongfully denied by The Standard Insurance Company and Hartford Financial Insurance Company.
Eric Wilson has brought a lawsuit in the United States District Court of the Eastern District of Louisiana against Reliance Standard Insurance Company and Lincoln National Life Insurance Company because the companies have refused to reply either pro or con to his petition for disability benefits in compliance with his insurance policy contract.
A recent Sun Life disability claim by a gunshot victim ended up as a lawsuit in the Orange County Superior Court because of the reluctance of the disability insurance company to pay out any long term benefits to its plan’s participants. In Marilyn Ellis v Sun Life Assurance Company of Canada, the plaintiff Marilyn Ellis with her California disability attorney contended that she was at all times a participant to a group long term disability plan with the policy number 63311 that was provided by the Sun Life Assurance Company (Sun Life). As such, she argued that she was a beneficiary of the plan and is entitled to the long term disability benefits that were offered in the plan.
In any claim for any disability benefits, the deciding factor which disability insurance companies will decide on will be whether you are what they define as being “disabled” or not. Most insurance companies however, will try to define the scope of what constitutes “disabled” as narrowly as possible to their advantage. The situation is especially compounded when a claimant is disabled due to substance abuse. Substance abuse cases involved both physical disabilities and mental disabilities…
Disability Blog & Cases:
SunLife & Aetna Life Insurance Company sued for denial of disability benefits
Here are examples of two recent cases in which SunLife Insurance Company and Aetna Life Insurance Company had a structural conflict of interest and denied disability insurance benefits. In most long term disability insurance claims which are governed by ERISA there is an inherent structural conflict of interest. The conflict of interest exist because the disability insurance company not only pays the benefits, but has the ultimate authority to approve or deny benefits. How can a disability company act a fiduciary to the insured when at the same time a decision to pay benefits will reduce the net income of the company?
The United States Court of Appeals for the Ninth Circuit recently ordered a lower court to reconsider its decision that had affirmed Hartford Financial Insurance Company‘s denial of a woman’s claim for disability benefits. Although the claimant has not yet been awarded her requested disability benefits, the Appeals Court’s decision leaves her one step closer to achieving this goal.
Disability Insurance Attorneys Dell and Schaefer filed a Federal Lawsuit against Life Insurance Company of North America (LINA), which is part of CIGNA Corp (CI.N). The lawsuit was filed after Cigna refused to pay disability benefits to a Florida teacher forced to stop working due to mental health issues such as depression, bipolar disorder and schizophrenia.
A Federal lawsuit filed in United States District Court Southern District of Florida accuses the Hartford Life and Accident Insurance Company of breaching its contract with Branch Banking and Trust (BB&T) and a BB&T employee. Filed by noted disability insurance law firm of Dell & Schafer, the suit states that Hartford is refusing to pay benefits to the employee, a U.S. Patriot Act/Anti-Money Laundering Analyst. The refusal by The Hartford violates the Employee Retirement Income Security Act of 1974, commonly referred to as ERISA.
Disability Blog & Cases:
Disability insurance lawsuit against Guardian Life Insurance serves as warning to doctors
A lawsuit filed in the United States Southern District Court of New York reveals that The Guardian Life Insurance Company of America is refusing to pay long term disability insurance benefits to a New Jersey OB/GYN critically injured in a car accident.