When Dr. Beatriz Martinez received a letter from MetLife denying her claim for long-term disability insurance, her only remaining option was to file a lawsuit. Unfortunately for her, the court upheld Met Life’s denial for one primary reason, she filed her claim for disability benefits four months too late. No arguments put forth by her attorneys could change that fact, and in the end, her appeal was denied, and she lost her lawsuit.

This issue arises far too frequently. Let’s look at Dr. Martinez’ story. There are important lessons for all of us.

→ Click here to continue reading Late Application Filing Results In MetLife Denying A Physician’s Long-Term Disability Claim

Mrs. Pettigrew was an employee of Pioneer Automotive Technologies, Inc from December 8, 2003 until May 15, 2006. Her most recent position was that of a senior engineer. Mrs. Pettigrew had been experiencing increasing pain and symptoms of Chronic Fatigue Syndrome (CFS), Fibromyalgia and Radiculopathy. Because of the increasing problems Mrs. Pettigrew was facing, she was finally forced to stop working. On May 25, 2006 Mrs. Pettigrew submitted a claim for short-term disability benefits, claiming that she was unable to work due to fatigue, severe pain causing lack of concentration, difficulty sitting as well as standing.

→ Click here to continue reading Prudential Ordered To Re-evaluate Long-Term Disability Claim of Engineer Suffering From Chronic Fatigue Syndrome and Fibromyalgia By Court

For several years, Elizabeth Black was the executive director of Milwaukee World Festival, Inc. (MWF), the organization that governs Summerfest, a music festival in Milwaukee. Black was covered under the company’s disability insurance plan, underwritten and administered by Standard Insurance Company. Black was diagnosed with multiple aortic aneurysms bulging and weak areas in the aorta. In 2001, Black had surgery to repair the aneurysms and was recommended by her doctor to medically manage a third aneurysm in the descending aorta.

→ Click here to continue reading Standard Insurance Company’s Denial Of Disability Benefits Is Upheld By Court, Despite Claimant’s Approval Of Social Security Disability Benefits

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.

→ Click here to continue reading MetLife’s Denial Of Long-Term Disability Benefits to a Senior Project Manager Suffering From Back Pain Is Reveresed By A Federal Judge

Annette Engel was employed with Harborcreek Youth Services as a Clinical Director, where she performed duties such as providing leadership and vision, developing proposals, overseeing interviews and recruits of other clinicians, consultation and more. On September 5, 2007, Mrs. Engel applied for long term disability benefits under her employer’s plan with Jefferson Pilot (aka Lincoln National), claiming fibromyalgia, chronic fatigue, stress, and depression resulting from working long hours.

→ Click here to continue reading Disability Benefits Ordered To Paid By Jefferson Pilot To A Clinical Director Suffering From Fibromyalgia, Chronic Fatigue And Depression

Mrs. Rebecca Duperry worked as payroll benefits HR administrator for Railroad Friction Products Corporation (RFPC) until April 7, 2006. Mrs. Duperry suffered from rheumatism, and stopped working in April pursuant to the advice of her rheumatologist. The rheumatologist told Duperry to ‘slow her work down’ and that cutting hours was a good idea, although working from home would be an even better idea.

October 16, 2006, Duperry claimed disability from three conditions,  rheumatoid arthritis, osteoarthritis and fibromyalgia. Among the documents Mrs. Duperry submitted to CIGNA Life Insurance Company of North America were two attending physician statements completed by Duperry’s primary care physicians, Dr. Glenn Harris, and her rheumatologist, Dr. Supen Patel. In his statement, Dr. Harris stated that “plaintiff was limited to zero hours per day of climbing, balancing, stooping, kneeling, crouching, crawling, reaching, walking, sitting, or standing, and that plaintiff would "never" be able to return to work.” A statement was made also by Dr. Patel that Duperry was ‘permanently disabled’ and therefore could not return to work.

→ Click here to continue reading Disability Benefits Ordered To Be Paid By CIGNA To HR Administrator Diagnosed Fibromyalgia

Walter Pettway was employed with ADP (NASDAQ: ADP), as a principal consultant, beginning in 1994.  Mr. Pettway’s job required him to travel the United States helping large corporations with computer processes.  In the 1970’s, Mr. Pettway had undergone a cervical fusion at the C6-7 level and at the C5-6 level in 1999.  In the summer of 2002, Mr. Pettway suffered a fall which aggravated his condition, so that he experienced issues with his neck, lower back, left arm, right and left leg weakness and numbness in his fingers.  In October 2002, Mr. Pettway began treating with and orthopedic surgeon, Dr. Ragab.

Mr. Pettway underwent a cervical discectomy and fusion from C3 to C5 with an allograft and placement of anterior instrumentation on January 21, 2003.  Because of continued finger numbness and neck pain, Mr. Pettway underwent another surgical procedure to remove the hardware on June 24, 2003.  Continued pain led Mr.Pettway’s orthopedic surgeon to suggest his pain and numbness was a result of scarring from past surgeries.

 

On January 20, 2003, Mr. Pettway applied for long-term disability benefits with Prudential as outlined in the plan he was part of with his workplace.  He claimed disability for the recent cervical issues, pain and numbness as well as a history of diabetes and high blood pressure. Submitted with the disability claim was a statement of Dr. Ragab, indicating that the patient had been diagnosed with cervical spondylosis and herniated nucleus pulposus.  Prudential initially approved Pettaway’s claim for disability benefits.

 

Disability benefits were received until December 1, 2003 because Prudential stated that Mr. Pettway was no longer qualified to receive them.  At this point with the policy, Mr. Pettway could only be considered disabled if he were not able to perform the duties of any job as opposed to only the duties of his job.  Along with an appeal on November 25, 2003 Mr. Pettway submitted a statement from Dr. Ragab on December 5, 2003, stating that Mr. Pettway was, “unable to perform the duties of any gainful occupation which he is reasonably fitted by education, training and experience.”

 

A Prudential-initiated independent medical exam by Dr. Thomas Cullom, a neurological surgery specialist, was scheduled on January 7, 2004.  Dr. Cullom concluded that Pettway was unable to perform the duties of his own current occupation.  Prudential reinstated benefits on January 22, 2004.  Multiple attempts to perform surveillance on Mr. Pettway happened between February 2004 and November 2007.  At one point, Prudential had video of a man they thought was Mr. Pettway.  However, it was proven not to be and those videos were disregarded.  There was one video of Mr. Pettway driving to a car rental location, placing two bags in the car and driving for an hour.

 

Another independent medical examination was scheduled with Dr. Jo Lynn Polk, on November 16, 2007.  After examining Pettway, reviewing his medical records, and watching the surveillance video of Mr. Pettway, Dr. Polk concluded that the patient’s, “self-reported functionality is not consistent with the activities noted on the surveillance.”

 

Other claims by Dr. Polk include, "(1) although he claims his left hand is weak, there was no atrophy of his left hand muscles; (2) although he says he has numbness in his left hand, there was only a slight sensory deficit which would impart minimal impaired function of the left hand; (3) although he says he can sit for only 30 minutes at a time, he sat on the examining room table for one hour during my interview; and (4) although he says he needs assistance standing and wiping himself after bowel movements, during my evaluation he demonstrated independence with standing after sitting and had adequate right shoulder internal rotation to wipe himself after bowel elimination."

 

As far as standing without assistance, Dr. Polk repeated only what a nurse relayed to her – these observations were not made firsthand.

 

Prudential had an in-house physician, Dr. Day, review Dr. Polk’s report and he concluded, “I would agree with the conclusion Dr. Polk noted that the claimant has sustainable work capacity at least at a sedentary level. There were several inconsistencies in the physical examination by Dr. Polk.”

 

In another appeal, Mr. Pettway submitted letters from three physicians (Dr. Ragab, Dr. Cullom and Dr. Bouldin), which disagreed with Prudential’s findings.  Prudential denied benefits and stated in a letter sent June 11, 2008 that Mr. Pettway has the functional ability to perform duties of jobs other than his own, which he is well-trained and qualified for.

 

In the United States District Court for the Southern District of Mississippi, Hattiesburg Division, it was found that Prudential completely ignored irrefutable evidence of Mr. Pettway’s condition by his treating physicians.  Instead they relied on Dr. Polk’s assessment, a physician who saw him for less than an hour.  The video evidence was disregarded, both because Prudential had been unsuccessful at surveying Mr. Pettway most of the time and had blundered in their attempts to do so and because nothing in the videos suggested that Mr. Pettway was able to perform the duties of any job with reasonably continuity.  Because of this, the court ordered Prudential to reinstate Mr. Pettway’s long term disability benefits.

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.

In February of 2006, Mrs. Lanoue was a table games floor person for the Mohegan Tribal Gaming Authority and had been since October of 1997. She was covered under the long-term disability plan issued and funded by Prudential Insurance Company of America (NYSE:PRU). In April of 2006, Mrs. Lanoue filed for long-term disability, claiming to have chronic pain, fatigue and fibromyalgia. Her claim included an employee statement and an attending physician’s statement (APS) from rheumatologist, Dr. Sandeep Varma.

→ Click here to continue reading Conneticut Court Rules Against Prudential After They Fail To Recognize Pain Caused By Fibromyalgia As A Long Term Disability

Individuals who pay for disability insurance premiums hope to be able to rely on the disability benefits if they are ever unable to work for any extended period of time. However, many times these employees’ claims are denied without any reasonable basis for denial. As in the case below, it is often abusive claims handling tactics by disability insurance companies that leads to disabled individuals being denied their benefits and forced to try and support their families in any way that they can.

→ Click here to continue reading New York Federal Court Exposes Unum’s Disability Claims Handling Tactics

Karen Bloom was a partner and doctor specializing in physical medicine and rehabilitation at Rehabilitation Associates in Louisville, Kentucky. In 1999, she was diagnosed with Multiple Sclerosis (MS). In 2002, she decided to perform most of her work on an outpatient, rather than inpatient basis.

At the beginning of 2004, Dr. Bloom became unable to continue working full-time for Rehabilitation Associates because of her MS. She subsequently transitioned into part-time work and filed a claim in March 2004 for long-term disability benefits under the group policy provided by Hartford through her employer since 2002.

On September 21, 2004, Harford denied Dr. Bloom’s claim. In its denial, Hartford claimed that Dr. Bloom had a pre-existing condition, based on a date of disability of December 1, 2002. Through her attorney, Dr. Bloom appealed the denial. While admitting that she had a condition that existed prior to the effective date of the policy (October 2, 2002), Dr. Bloom’s position was that she became disabled after the 365-day elimination period had run, since she had claimed a date of disability in 2004, and thus was still entitled to coverage under the policy. Hartford’s position was that when Dr. Bloom transitioned from inpatient to outpatient work, she did so because of her MS, and thus had reduced hours in 2002 because of her condition.

Hartford contacted Dr. Bloom’s doctors, who agreed that she was disabled, but not until 2004. Despite the full support of her doctors, Hartford denied her appeal on July 8, 2005. In its denial letter it recited the same incorrect information it had relied upon in its previous denial. In response, Dr. Bloom filed suit in Federal Court. The federal court granted summary judgment in favor of Dr. Bloom after concluding that Hartford’s decision was arbitrary and capricious because it had relied on circumstantial evidence of her disability – work records and salary reports – rather than the medical records that existed between Hartford’s determined date of disability and Dr. Bloom’s claimed date of disability. Hartford appealed the trial court’s decision to the Sixth Circuit Court of Appeals.

On appeal, the decision to award benefits to Dr. Bloom was upheld. However, the court ordered that Hartford conduct the appropriate evaluation as to the true date of disability and to determine the amount of benefits owed to her.

From a practical standpoint, this case highlights two important points. One, it is vitally important to have an attorney involved in filing a claim as soon as possible. Had an attorney been involved at the outset at the filing of the claim, Dr. Bloom could perhaps have avoided leaving the door open for Hartford to deny her based on a pre-existing condition. Two, while Dr. Bloom won her case, because of the decision on appeal she is still subject to the whims of Hartford in picking a date of disability and determining the benefits that she is owed. Ultimately, she may have won the battle for entitlement to benefits, but lost the war, since Hartford still controls her date of disability and how much money she will receive under the disability policy.

See Bloom v. Hartford Ins. Co., No. 07-6374 (6th Cir. Jul. 21, 2009).

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.