Disability Benefit Claims Law Blog

CIGNA Settlement

Gregory Dell — Thu, 30 May 2013 07:35:11 -0500

Cigna Insurance Company can run but they cannot hide from the Department of Insurance in five states.

This time Cigna will have to pay fines in excess of $1.6 million and potentially over $77 million in unpaid long term disability benefits. Watch our video or visit us at www.diattorney.com/CignaSettlement to learn if you are eligible to have your previously denied claim reassessed. If you have any questions at all about your entitlement to benefits or would like assistance, contact us for a free immediate consultation.

Supreme Court Grants Writ of Certiorari in ERISA Lawsuit, HEIMESHOFF V. HARTFORD

Gregory Dell — Mon, 13 May 2013 03:19:26 -0500

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 Second Circuit Court of Appeals cited to the following: ERISA does not contain a specific limitations period for challenging the denial of benefits. See Burke v. PriceWaterHouseCoopers LLP Long Term Disability Plan, 572 F.3d 76, 78 (2d Cir. 2009). Instead, the controlling limitations period is provided by the "most nearly analogous state limitations statute." See id.

Heimeshoff argued that the 3-year statute of limitations defined in Hartford's policy did not begin to run until the final of denial of benefits. Connecticut's general statutes contain a 6-year statute of limitations for contract actions, which applies in this case. However, under Connecticut law, parties to an insurance contract may shorten the statute of limitations period to not less than one year. Additionally, pursuant to Burke (572 F.3d at 81), a statute of limitations specified by an ERISA plan for bringing a claim under Section 1132, may begin to run before the claimant can file a lawsuit.

Hartford's Plan stated that the 3-year statute of limitations period began from the time that proof of loss was due pursuant to the Plan. Because the policy language was unambiguous and it is permitted under the statute to have the limitation period begin before the claim accrues, the Circuit court found that Heimeshoff's action was time-barred.

The Supreme Court will now review this matter solely as to the question, "When should a statute of limitations accrue for judicial review of an ERISA disability adverse benefit decision?"

Aetna is Entitled to Reimbursement of Overpaid Disability Insurance Benefits from Claimant Involved in Car Accident

Gregory Dell — Tue, 16 Apr 2013 08:09:20 -0500

In the matter Thurber v. Aetna, Aetna brought a counterclaim against Thurber for the return of overpaid short-term disability benefits pursuant to ERISA 29 USC §1132 (a)(3), which authorizes civil actions brought to obtain appropriate equitable relief to enforce any provisions of this subchapter or the terms of the plan. Thurber had an auto accident and was receiving no fault insurance benefits and STD payment. Thurber’s STD policy stated that benefit paid by a n-fault auto insurance company would offset the STD benefit. Aetna paid the STD benefits and sought an overpayment for any funds paid by the auto insurance carrier.

Is Aetna Entitled to Recover An Overpayment If Car Insurance Company Pays No Fault Benefits?

The questions in this matter are 1) does reimbursement of the overpaid STD benefits in this case qualify as appropriate equitable relief or legal relief, and 2) did the district court have subject matter jurisdiction over the counterclaim for equitable relief. The appellate court found that Aetna, under the terms of the disability insurance Plan, was entitled to recover the sought amount of overpaid disability benefits as the overpayment qualified as equitable relief under ERISA, and therefore, the district court did have subject matter jurisdiction and the case was remanded back for the district court to find in favor of Aetna. The court cited 2 authorities to determine whether the nature of Aetna's claim was equitable: Great West v. Knudson and Sereboff v. Mid Atlantic.

In Great West, the insurer attempted to seek reimbursement of paid benefits from a third-party settlement, wherein the settlement funds were directed into a Special Needs Trust. ERISA provides only equitable, not legal, remedies to plan administrators to redress violations of the plan or to seek reinforcement of plan provisions. Because Great West was seeking funds which were sequestered into a trust, not distributed directly to the Knudsons, it was determined that Great West was trying to impose personal liability upon the Knudsons to seek subrogation of funds paid, which is an action of law not equity. Alternatively, in Sereboff, Mid Atlantic sought reimbursement of amounts paid to cover medical expenses under their ERISA plan from the Sereboffs third party settlement. The third party settlement funds were distributed directly to the Sereboffs and the Sereboffs set aside the sought amount until the Mid Atlantic lawsuit was decided. The court found the nature of relief sought by Mid Atlantic was equitable because the ERISA plan specifically identified a particular share of particular funds that were subject to return, and therefore there existed an equitable lien on those settlement funds. The Sereboffs tried to argue that Mid Atlantic needed to satisfy tracing rules, but the Court confirmed that tracing rules did not apply where there was an equitable lien by agreement.

Aetna's claim was found to be equitable because the funds being sought were overpayments resulting from Thurber's receipt of no-fault insurance benefits, while she was receiving short-term disability benefits. A specific overpayment amount was identified and it was established that those funds were entrusted to Thurber. Aetna's Summary Plan Description contained language which provided that Aetna "may" reduce benefits if the beneficiary receives other income, and "may" require the beneficiary to reimburse any benefits that were overpaid. The district court determined that the use of the word "may" implied that Aetna reserved discretion to decide whether or not they would seek reimbursement, and therefore converted the right to subrogation into a legal act, rather than an equitable act.

Aetna Was Not Aware That Claimant Was Being Paid No-Fault Benefits and STD Benefits At the Same Time

The appellate court found that, had Aetna been aware that Thurber was receiving the no-fault benefits while they were paying the short-term disability benefits, they would have had the right under the terms of the plan to reduce the amount of the disability benefits paid to Thurber. Because Aetna had the right to reduce the benefit amount at the time she was receiving the benefits, they now retained the right under the subrogation provision of the plan to seek return of the overpayment amount. This specific provision in Aetna's plan created an equitable lien by agreement over this particular, identifiable sum (the amount overpaid). Thurber also argued that the funds overpaid by Aetna had already been spent. The Court in this case positioned with the Third Circuit whereby, if “there was an equitable lien by agreement that attached to the [third-party benefits] as soon as [the beneficiary] received it, dissipation of the funds [is] immaterial.” Funk, 648 F.3d at 194. Where an ERISA plan created an equitable lien by agreement, as opposed to an equitable lien sought as a matter of restitution, it only matters that the beneficiary did at some point have possession and control of the specific portion of the particular fund being sought by the insurer.

It was found that Aetna did present an appropriate claim for equitable relief under the terms of the ERISA plan, and accordingly, the district court did, in fact, have subject matter jurisdiction over Aetna’s claim. The claimant will be required to repay Aetna for any overpayment.

Attorneys Dell & Schaefer represent disability claimants at all stages of a claim for disability benefits and we always offer a free consultation. This claim was not handled by our law firm.

Court Rules United of Omaha Life Insurance Company Did Not Act Unreasonably in Denying Disability Insurance Benefits to Woman With Fibromyalgia

Gregory Dell — Mon, 04 Mar 2013 06:38:01 -0500

A Tennessee Plaintiff filed an ERISA lawsuit regarding the denial of her short term disability and long term disability benefits, contending that 1) she was disabled under the terms of the plan; 2) that United of Omaha Life's reliance upon the opinions of medical experts who did not physically examine her was inadequate to provide a reasoned explanation for its decision to deny benefits; and 3) that the plan's self-reported symptoms provision provides for disability payments for up to 2 years.

In this case, the terms of Plan delegated to United of Omaha Life full authority and discretion to make eligibility determinations for benefits and to interpret the terms of the Plan, for both short term and long term disability. Because of this, the Tennessee court applied the arbitrary and capricious standard of review. Accordingly, the court was charged only with the task of deciding whether United of Omaha Life's decision to deny short term and long term benefits to the Plaintiff was based on a reasonable interpretation of the Plan.

Was Ms. Holden disabled under the terms of the Disability Plan?

In order to satisfy the definition of disability under the terms of United of Omaha Disability Plan, the Plaintiff, Ms. Holden, was required to establish that, as a result of injury of sickness, she has a "significant change in Your mental or physical capacity and You are: a) prevented from performing at least one of the Material Duties of Your Regular Occupation on a part-time or full-time basis; and b) unable to generate Current Earnings which exceed 99% of Your Basic Monthly Earnings due to that same Injury or Sickness. After a Monthly Benefit has been paid for 2 years, Disability and Disabled mean You are unable to perform all of the Material Duties of any Gainful Occupation." The Plan further stated that to receive a monthly benefit, acceptable proof of loss must be provided.

Disability Claim Based on Fibromyalgia, Lupus and Migraines

Ms. Holden had a long documented medical history of accelerated chest pain syndrome, cardiac catheterization with normal findings, noted lupus erythematosus, migraine headaches, noted fibromyalgia, small L1-2 disc protrusion without impingement and minimal L4-5 facet joint degenerative changes, with complaints of symptoms such as heart palpitations, muscle and joint pain, fatigue, arm pain, ankle swelling, syncope, near-syncope, and difficulty with prolonged sitting, rising and lifting.

When Ms. Holden filed her initial claim for short term disability benefits in February 2009, she was treating with her primary care physician, a nurse practitioner, rheumatologist and a cardiologist, with complaints of edema, palpitations, arm pain, nausea and rear syncopal feeling. In May, Ms. Holden was awarded short term disability benefits up to 4/21/2009 as United of Omaha Life's Nurse Case Manager found that the medical records were sufficient to support restrictions and limitations up to the 4/21/09 office visit with the cardiologist while she was being evaluated for angina and her medications were being adjusted. However, her cardiac conditioned had stabilized as she was not required to follow up with the cardiologist for 6 months, and her main complaints at this point were related to fibromyalgia and lupus.

It should be noted that although fibromyalgia is characterized by subjective complaints of pain and fatigue, there are widely accepted diagnostic tests which are used to objectively establish a diagnosis of fibromyalgia. These tests involve identifying specific "tender points" on the patient. If the patient possesses a minimum of 11 out of the 18 defined tender points, they are eligible for a diagnosis of fibromyalgia. In this case, Ms. Holden never met the criteria for a diagnosis of fibromyalgia and laboratory tests did not confirm a diagnosis of lupus, which also produces subjective symptoms such as generalized pain and fatigue.

Additional medical records were requested and provided to United of Omaha Life, and a second review of the medical file concluded that continued restrictions and limitations were not supported beyond 4/21/09 because Ms. Holden had not demonstrated the she was unable to perform her job duties which were classified as sedentary. United of Omaha Life denied further disability benefits and Ms. Holden appealed.

Ms. Holden continued to treat with her medical providers and submitted her appeal to United of Omaha Life in December 2009 and in January 2010, a third review of the medical file was conducted and determined that the medical information lacked objective physical and diagnostic findings which supported restrictions and limitations that would preclude Ms. Holden from performing the material duties of her regular sedentary job. The denial letter included a detailed summary of the review of the medical records that was performed.

Ms. Holden continued to treat for her generalized symptoms, but physical examinations and diagnostic testing resulted with normal findings.

In June 2010, Ms. Holden applied for long term disability benefits due to pain, inability to get out of bed and inability to drive. A physician's statement indicated she could not work because of fibromyalgia, osteoarthritis, lupus and migraine headaches. United of Omaha Life had their Senior Vice President and Medical Director, Dr. Reeder, review Ms. Holden's medical record. Dr. Reeder concluded that Ms. Holden did not meet the accepted criteria for a diagnosis of fibromyalgia or rheumatoid arthritis, and that there was no medical evidence to support functional loss or that Ms. Holden was incapable of working in a sedentary occupation. In December 2010, Ms. Holden's long term disability benefits were denied and she appealed.

During the appeal, Ms. Holden underwent an arthroscopy surgery, which was tolerated well, and a follow up with her rheumatologist indicated her FMS score was 5/18 with no weakness.

United of Omaha Life retained a rheumatologist, Dr. Peck, to perform a review of Ms. Holden's medical records. Dr. Peck noted that Ms. Holden's records indicated that she did not fulfill the criteria for fibromyalgia, and lab results indicated a false positive ANA with no evidence of lupus or other connective tissue disease. Dr. Peck opined that the restrictions and limitations provided by the treating physicians were not supported with medical evidence of impairment, even in the doctors' own notes, and that Ms. Holden is capable of light work on a full time basis. The restriction to light work results from the facts that she has internal derangements of her knees, lumbar spondylosis and myofascial pain syndrome. Based on Dr. Peck's review, United of Omaha Life upheld its denial of long term disability benefits.

While Ms. Holden claimed that she was disabled under the terms of the Plan, she conceded that she was not able to clearly prove through her records that she was disabled, but that her claim was entirely dependent on subjective evidence of her disability. She further argued that the Self-Reported Symptoms provision of the plan, in and of itself, was enough to prove that her self-reported symptoms were sufficient evidence of disability. However, United of Omaha Life responded that while self-reported symptoms may be used as evidence of an illness, Ms. Holden still must provide sufficient objective evidence of disability from such an illness. The Court in this case recognized that, while it is unreasonable to require objective evidence of a subjective illness, objective evidence of disability may be required, even when the alleged disability stems from fibromyalgia, as long as the Plan administrator notifies the claimant that it requires additional objective evidence of the disability.

In this case, United of Omaha Life repeatedly requested, from both Ms. Holden and her physicians, objective medical evidence to support her claim of disability and inability to perform her job. Ms. Holden and her physicians failed to submit sufficient objective evidence and several of her treating physicians actually indicated to United of Omaha Life that she was not restricted to perform sedentary work.

Was United of Omaha Life's reliance upon the opinions of medical doctors that never examiner the claimant Sufficient to support a disability denial?

Ms. Holden further alleges that United of Omaha Life acted unreasonably by basing its decision to deny benefits on the opinions of "non-examining file reviewers", rather than having a physical examination performed. The court found that there was no Plan language which barred a medical file review in lieu of a physical examination.

The independent medical reviewers retained by United of Omaha Life were of the appropriate medical specialties and it is apparent in their reports that they greatly considered the treatment, assessments and opinions of Ms. Holden's treating physicians. The independent reviewers also provided the treating physicians with the opportunity to respond and provide comment on the reports. Dr. Reeder noted that Ms. Holden's rheumatologist refused to respond and suggested she be referred for a functional capacity examination. Her cardiologist advised that her chest pain was non-cardiac in nature and that she did not have any work restrictions, including driving. Dr. Reeder wrote to Ms. Holden's nurse practitioner citing his review of the medical records, and indicating that, in his opinion, the records did not support restrictions and limitations which precluded Ms. Holden from performing her sedentary occupation. Dr. Reeder requested that any information with physical exam or diagnostic test findings, or other objective evidence to support work restrictions and limitations be submitted. The nurse practitioner's office informed United of Omaha Life that she would not be responding because she agreed with Dr. Reeder's letter/assessment. Other additional records submitted by Ms. Holden's treating physicians noted that she did not have any work restrictions or limitations.

Because the independent medical reviewers actually gave great weight to the medical record, and went so far as to contact the treating physicians, by telephone and by letter, to discuss Ms. Holden's case, under the arbitrary and capricious standard of review, United of Omaha Life did not act unreasonably by relying on their opinions as a basis for the decision to deny Ms. Holden's benefits.

Outcome of the ERISA Lawsuit Against United of Omaha

The Tennessee Court found that United of Omaha Life did not act unreasonably and its decision to deny Ms. Holden's short term and long term disability benefits was not arbitrary and capricious. The court granted United of Omaha Life's motion for judgment on the record and denied Ms. Holden's motion for judgment.

Ms. Holden's claim of disability was based solely on subjective complaints of pain and fatigue. All of the objective measures, even for such subjective syndromes such as fibromyalgia and lupus, had negative results for Ms. Holden and no firm diagnosis could be established which would support her claim for disability. Even Ms. Holden's treating physicians did not support her in her claim for disability. Our law firm did not handle this claim.

Ms. Holden and her disability lawyers incorrectly relied on a self-reported symptoms policy provision as a means to prove her disability claim, when the purpose of that provision was to acknowledge that some conditions are diagnosed based on subjective symptoms, and to establish that in such an instance, the disability benefits would be limited to 24 months. This case is another example of how important it is to have strong physician support in order to obtain of approval of long term disability benefits.

If you have a disability insurance claim and would like to know your legal options, contact Attorneys Dell & Schaefer for a free consultation.

Diagnosis of Fibromyalgia With Tender Point Test Is Essential in Disability Insurance Claims

Gregory Dell — Wed, 27 Feb 2013 06:33:09 -0500

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.

Hartford Insurance Company Refuses to Hear Late ERISA Disability Appeal and Missouri Court Agrees

Gregory Dell — Fri, 15 Feb 2013 06:54:43 -0500

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.

Do you think ERISA Disability Insurance Laws are fair?

Gregory Dell — Fri, 08 Feb 2013 09:37:43 -0500

As national disability insurance lawyers, every day we hear from disability claimants that have been denied long term disability benefits. Most of the these disability claimants have disability policies that are governed by ERISA. We want to get some public opinion from a claimant’s perspective about whether ERISA is a fair law. Please post your comments on our blog so that we can spread the word about changes that must be made to ERISA laws. Here is a recent comment from someone that emailed us earlier today:

I want to help other people with this issue! It’s a serious problem with have in the disability insurance industry. If the law would allow bad faith claims to filed, then it is my opinion that the bad faith denials would stop.

As of now they can deny all they want without suffering any type of penalty or slap on the wrist and hence these issues will continue. To not even award attorney fees is just outright wrong. I'm out 401k , my own funds, it sank me financially and I m out attorney fees. And my issue is easily proven to be bad faith. So, this is just wrong in so many ways the very fact that this ERISA law has been around since 1974 is really disgusting that this has not been fixed. It was initially put forward to stop people from frauding insurance. But now the insurance companies are taking it using this loop hole to commit fraud against a claimant now. Obviously the ERISA act is broken due to this allowance of not penalizing the insurance for wrong doing.

Anyway, I hope Dell & Schaefer and other firms unite and fight and Ill be more than happy to join it. So many are suffering over this and have lost everything we have. I just hope if something did change it would allow those who got punked due to bad denials are allowed to recover losses if they do change something.

Texas Disability Lawyers Expose the Insurance Company Shell Game In Another AT&T Disability Denial

Gregory Dell — Tue, 26 Jun 2012 11:42:26 -0500

Quite often, insurance companies create a maze of entities that could confuse the most cautious policy holders. One entity may own the fund. Another entity may administer the fund. So who should a plaintiff sue when these corporate entities conspire to break a promise to pay disability benefits? Fortunately, skilled disability lawyers know these insurance company tricks and can figure out who is ultimately responsible for a wrongful denial of disability benefits. Sometimes, it depends on bringing the right claim against the right party.

The case of Franklin v. AT&T Corporation is a prime example. The plaintiff worked at AT&T as a systems analyst for eleven years. She had long-term disability benefits under the AT&T Long Term Disability Plan for Management Employees ("the Plan") that were administered by Metropolitan Life Insurance Company ("MetLife'). Sedgwick Claims Management currently handles all AT&T disability claims. In 1999, the plaintiff filed for and received the long-term disability benefits arising from a number of causes including Crohn's disease, breast cancer, chemotherapy, chills, night sweats, nausea and depression.

Three years later, MetLife reevaluated the plaintiff's eligibility for long-term disability benefits. MetLife had demanded that the plaintiff apply for Social Security disability insurance benefits and, when she obtained them, reimburse the Plan for all the social security benefits she received when the Social Security Administration agreed she had been totally disabled since 1999. Soon after cashing the check, MetLife determined that the plaintiff was not in fact totally disabled and stated she could return to full-time work in other occupations. This conclusion led MetLife to deny the plaintiff's claim for continued long-term disability benefits.

The plaintiff sued, arguing that her long-term disability benefits were wrongfully denied by MetLife and the Plan. Both defendants filed a number of motions. MetLife challenged the plaintiff's ability to hold the insurance company accountable for its role in denying coverage because AT&T had fired MetLife as the plan administrator more than a year and a half before the plaintiff filed suit. The Plan claimed that the denial was within its discretionary authority.

The Court Awards Disability Benefits for What MetLife Did

A federal court in Dallas ruled that the plaintiff was entitled to long-term disability benefits and that MetLife was entitled to be dismissed from the lawsuit as it was merely the administrator. The plaintiff could only recover the disability benefits from the Plan because it had not brought a claim against MetLife for breach of the duty of good faith and fair dealing, which requires Texas insurance companies to treat policy holders in a certain manner. Nonetheless, MetLife's actions were the central focus of why the court held the Plan responsible. The court specifically noted:

MetLife had distorted the opinions of treating physicians when it characterized the plaintiff as able to return to full-time work;
MetLife had not given adequate consideration to the determination for Social Security purposes that the plaintiff was totally disabled; and
Though relying on the availability of leave under the Federal Medical Leave Act to claim that the plaintiff could be absent from work to accommodate her illness, MetLife failed to recognize that, as a new employee, the plaintiff was not eligible for leave under the FMLA for twelve months.

While MetLife wasn't financially responsible to the plaintiff in this case, other companies may think twice before employing MetLife as a plan administrator in the future. The federal court held that MetLife had "cherry-picked" facts in the administrative file to support its position and, for this reason, MetLife had acted in an arbitrary and capricious manner. These wrongful actions persuaded the federal court to order the Plan to reinstate the plaintiff's long-term disability benefits. Ironically, the plaintiff could have prevailed against MetLife as well (above and beyond the disability benefits recovered against the plan) had the plaintiff's lawyer brought a claim for breach of the duty of good faith and fair dealing.

Franklin v. AT&T Corp., No.03:08-CV-1031-M, 2010 WL 669762 (N.D. Tex. Feb. 24, 2010)

This Week on DIAttorney.com (06/09/2012)

Gregory Dell — Sat, 09 Jun 2012 08:07:48 -0500

Disability Blog & Cases:
California Court denies Plaintiff’s Attempt to Introduce New Medical Information During ERISA Disability Lawsuit Against Hartford for Long Term Disability Benefits

One of the largest obstacles facing an insured in bringing a lawsuit against a disability insurance company for benefits under an ERISA governed group disability policy is the inability to add additional information, in most cases medical information, to the administrative record after a final denial has been entered by the insurance company.

Disability Blog & Cases:
Cigna Denies Disability Benefits, But Additional Information Could Have Resulted In A Victory

When filing a disability application or appeal it is of the utmost importance to provide the insurance company all of the relevant medical records and/or documentation supporting your disability in a timely manner.

If you fail to submit any important documents or records they will not be considered by the judge at a later date if your disability claim is denied.

This Week on DIAttorney.com (06/02/2012)

Gregory Dell — Sat, 02 Jun 2012 06:53:19 -0500

Disability Blog & Cases:
Boeing Employee Suffering From Severe Chronic Back Pain Sues Aetna For Denial Of ERISA Benefits

An Oregon disability lawyer has filed a lawsuit in the District Court of Oregon against The Boeing Company Employee Benefit Plan (Boeing) and Aetna Life Insurance Company (Aetna). The Plaintiff, Susan A, worked as an assistant to the Vice President and General Counsel of The Boeing Company. Due to her employment, Plaintiff was protected by Boeing's Employee Benefit Plan.

Disability Blog & Cases:
Unum Disability Denial With Medical Record Review Only

Can Unum deny disability claims and appeals by merely conducting paper reviews of a claimant’s medical records? Yes, apparently they can.

Disability Blog & Cases:
Sedgwick And AT&T Disability Denial Scheme Exposed In ERISA Lawsuit

On May 14, 2012, the U.S. District Court for the Northern District of California issued an order on a very hot topic for ERISA Disability Lawsuits. The issue concerns how much “Discovery” a denied person is able to obtain from the Disability Insurance Company while litigating a case.

FAQ: Appeals & Lawsuits:
If my long term disability benefits are governed by ERISA and I win at trial, does the insurance company have to pay me for the remainder of the policy life, or a lump sum amount?

Should your case go to trial under an ERISA governed disability plan and you win the insured is only entitled to an award of disability benefits that have not been paid by the insurance company. This is further contingent on whether the insurance company denied your claim under the “own occupation” or “any occupation” definition of disability...

This Week on DIAttorney.com (05/26/2012)

Gregory Dell — Sat, 26 May 2012 06:48:20 -0500

Disability Blog & Cases:
California Federal Court Finds That MetLife Abused Its Discretion And Awards Financial Analyst Long-Term Disability Benefits

Shelia W. and her California disability lawyer prevailed in a lawsuit against MetLife when the United States District Court of the Southern District of California found the insurer to have abused its discretion when it terminated Shelia’ disability benefits under the “own occupation” standard.

Disability Blog & Cases:
Sun Life Pays Disability Benefits For Three Years To A Claimant Who Wasn’t Actually Covered Under A Sun Life Policy

In the case of Pamela P. v. Sun Life and Health Insurance Company, the court record shows that Pamela P. applied for long-term disability benefits under an employee benefits plan that was maintained by Los Padres Bank for its employees and was awarded disability benefits for over three years. Said plan was underwritten by Sun Life with its Group Certificate governed by ERISA (the Employee Retirement Income Security Act)...

Disability Blog & Cases:
Another Cigna Hired Gun Doctor To Be Exposed!

Utah Court Wants To Know Relationship Between Dr. Carol Flippen and Cigna Life Insurance

Sedgwick Claims Management Services Sued by Hewlett-Packard Employee For Termination of Long-Term Disability Payments

Gregory Dell — Wed, 23 May 2012 17:44:12 -0500

The Plaintiff, Christopher L., with the help of his Texas Disability Attorney, has filed this lawsuit against Sedgwick Claims Management Services , Inc. (Sedgwick), Administrator of the Hewlett-Packard (HP) Company Disability Plan.

In Christopher L. v. Sedgwick Claims Management Services, Inc., Plaintiff has filed this lawsuit to regain all short-term and long-term disability payments that were wrongfully terminated.

Plaintiff's Rights of Disability Benefits Under The Plan

Plaintiff is a 44 year old man who is a citizen and resident of Tomball, Texas. Sedgwick was responsible for funding and administering the Plan, which Plaintiff was entitled to the benefits of based on his employment with HP as a Project Manager.

Plaintiff was forced to cease work on April 25, 2008 due to bipolar disorder, schizophrenia, chronic fatigue, diabetic neuropathy, memory loss, sleep issues, fibromyalgia, depression, vision problems, high blood pressure, and sunlight sensitivity.

Plaintiff filed applications for short term and long term disability benefits. Plaintiff's claim for short term disability benefits were granted by Sedgwick. Plaintiff later filed for long term disability benefits, which were initially granted by Sedgwick on December 1, 2008.

Sedgwick Changes Decision And Denies Future Long Term Disability Benefits

On August 20, 2010, Sedgwick denied further long term disability benefits to the Plaintiff. Plaintiff had 180 days to appeal this decision. The disability standard to apply in order to approve or deny a claim was being unable to perform "Any Occupation." If the application was approved, the Plan would pay a monthly benefit of $4,351.72.

Plaintiff requested an administrative review of the denial of benefits on December 6, 2010. Plaintiff included medical records to show his total disability, and thus, his argument for being approved for further long term disability benefits. In addition, the Social Security Administration issued a fully favorable decision on Plaintiff's claim for disability benefits under Title II and Title XVI of the Social Security Act.

Despite this, Sedgwick upheld its original denial on March 17, 2011. Sedgwick also informed Plaintiff that he had exhausted all administrative remedies. Due to this, Plaintiff has filed this lawsuit against Sedgwick.

Lawsuit Filed Against Sedgwick

Plaintiff filed a lawsuit against Sedgwick because Sedgwick discounted the opinions of Plaintiff's treating physicians, of others, and of the documented limitations that the Plaintiff suffers from due to his medical conditions, thereby preventing him from fulfilling the duties of any occupation and entitling him to the long term disability benefits as detailed under the Plan.

Plaintiff claims that Sedgwick failed to give proper weight to the evidence submitted to them regarding Plaintiff's condition and his inability to work. Plaintiff also claims that Sedgwick did not properly define disability as outlined in the terms of the Plan, calling it "unreasonable, arbitrary, and capricious." Plaintiff claims that Sedgwick failed to fulfill its contractual obligations to provide disability benefits to the Plaintiff.

The Relief Sought

Plaintiff wants a judgment against Sedgwick for the following:

All short term and long term disability benefits that have not been paid as of yet
All future short term and long term disability benefits according to the terms of the Plan for so long as the Plaintiff meets the terms of the Plan
All reasonable attorney fees and expenses due to the filing of this lawsuit
All other relief that the Court deems just and proper

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.

This Week on DIAttorney.com (05/19/2012)

Gregory Dell — Sat, 19 May 2012 06:47:25 -0500

Disability Blog & Cases:
Aetna Is Sued For Failure To Pay ERISA Benefits To Boeing Employee For Injuries Sustained In A Shooting

A Washington disability lawyer filed a federal lawsuit in the District Court for the Western District of Washington, at Seattle, against Aetna Life Insurance Company (Aetna) and The Boeing Company Long Term Disability Plan (Boeing). The Plaintiff, Patrick D., worked as a real-time software engineer for Boeing, which contracted with Aetna to provide long-term disability coverage to its employees. The Plaintiff’s employment with Boeing afforded him the protections under this Plan.

Disability Blog & Cases:
Unum Sued By An Ophthalmologist And A BJC Healthcare Employee Who Both Were Denied Disability Benefits

Unum Life Insurance Company Of America (Unum) was sued in two different lawsuits filed in the Federal Courts of Missouri, by two plaintiffs who did not receive the long-term benefits that were entitled to them under the terms of their respective Plans that were issued and administered by Unum.

Disability Blog & Cases:
Misrepresentation By Claimant Results in Unum Disability Claim Denial

Unum disability claimants need to be aware that when filling out an application for disability insurance benefits it is necessary to disclose your medical history accurately and to make sure your insurance agent is doing the same. Should the insurance company discover a material misrepresentation, the policy could be rescinded, and the claimant could be required to pay back any and all benefits previously paid and then be subject to a fraud investigation...

Northrop Grumman Employee Sues Unum For Violation of ERISA Rights and Reinstatement of Disability Benefits

Gregory Dell — Wed, 16 May 2012 17:32:58 -0500

In Hoang N VS Unum Life Insurance Company of America and Northrop Grumman Long Term Disability Plan, Plaintiff wants reinstatement of long term disability payments that were originally paid, then terminated, by Unum.

The Plaintiff, with the help of his California Disability Attorney, has filed this lawsuit in the United States District Court Central District of California against Unum.

Plaintiff's History and Reasons For Filing a Claim

Plaintiff worked as a systems administrator and network engineer at Northrop Grumman. His employment entitled him to be a participant in the Long Term Disability plan and other employee benefit plans that were established and maintained by Northrop Grumman.

Plaintiff suffered serious injury to his cervical spine when a heavy metal door fell on his head at work and knocked him to the ground unconscious. This accident caused the Plaintiff to become disabled as defined under the terms of the LTD Plan. Plaintiff filed a claim with the Defendants for LTD benefits under terms of the Plan. The Defendants originally approved the claim for LTD benefits.

Unum and Northrop Grumman Improperly Terminate Long Term Disability Benefits

On or about November 4, 2008, Defendants abruptly terminate the LTD benefits received by the Plaintiff. From the period of November 2008 through June 2009. Plaintiff's doctor reports that the Plaintiff was suffering from the following conditions:

Dysphoric mood
Excessive worrying
Insomnia
Confusion
Irritability
Lack of appetite
Intermittent suicidal ideation
Social isolation
Paranoia

Plaintiff filed an appeal of Defendants' denial on June 12, 2009. Unum replied to Plaintiff on June 15, 2009 that they could not review Plaintiff's claim because the appeal came after the 180-day deadline, meaning that the original decision on the claim must stand.

After Plaintiff received a Social Security Administration decision in his favor, Plaintiff again requested that Defendants reinstate his long term disability benefits on April 25, 2011. Once again, on May 2, 2011, Defendants deny Plaintiff's request.

Due to the fact that Plaintiff has exhausted all administrative remedies required under ERISA, Plaintiff has filed this lawsuit against Unum and Northrop Grumman.

Basis for Plaintiff's Lawsuit

Plaintiff claims that Defendants failed to allow Plaintiff to file an administrative appeal against California's notice-prejudice rule, which only prevents a person from filing an administrative appeal after a deadline if the Defendants are actually and substantially prejudiced by the delay. Plaintiff also claims that Defendants prevented Plaintiff from filing an administrative appeal when Defendants knew that the Plaintiff was suffering from severe cognitive problems.

Plaintiff also claims that Defendants did not provide any reasonable explanation of why Plaintiff's appeal was not considered, nor why his original claim was denied. Defendants also did not provide any explanation of what materials could have been added to increase the chances of a successful claim.

Plaintiff also claims that Defendants failed to adequately inform the Plaintiff of notice requirements under ERISA. Additionally, Defendants failed to properly investigate the merits of the Plaintiff's claim.

Type of Relief Requested from the Court

Plaintiff requests that the Court grant the following relief:

Plaintiff is able to file an administrative appeal of the denial of his original claim
The administrative appeal will be given full and fair consideration
All associated costs are paid
All appropriate attorney fees are paid
All other relief decided upon by the Court is fulfilled

This Week on DIAttorney.com (05/12/2012)

Gregory Dell — Sat, 12 May 2012 06:46:26 -0500

Disability Blog & Cases:
New York Federal Court Denies MetLife’s Motion To Dismiss Lyme Disease Victim’s Petition For Disability Benefits

In the case of Karen N. v. Metropolitan Life Insurance Company et. al, the United States District Court of New York, after hearing arguments from both sides regarding MetLife’s Motion to Dismiss the case, denied the motion in its entirety and directs the parties to appear for a status conference to determine how and when the case will proceed. And, while the Court did deny the insurer’s motion, that doesn’t mean that Karen N. will receive a favorable outcome in her lawsuit to receive her disability benefits. It does mean that the Court believes that the case deserves to be heard and ruled upon once all facts have been established.

Disability Blog & Cases:
Pennsylvania Pharmacy Owner Learns The Hard Way That Accuracy Is Everything When Applying for Disability Insurance Benefits

On January 28, 2011, the United Sated District Court of the Eastern District of Pennsylvania granted Berkshire Life Insurance Company of America’s Motion for Summary Judgment in Michael S. v. Berkshire Life Insurance Company of America, et. al. In addition, the plaintiff’s disability policy and FIO policy were rescinded negating...

FAQ: Social Security Disability Benefits
Can My Disability Insurance Benefits Be Denied If I Am Approved For Social Security Disability Benefits?

Disability Insurance Attorneys Gregory Dell and Cesar Gavidia discuss the misconception that a claimant will be approved for long term disability insurance benefits if social security disability benefits are approved.

Reliance Standard Sued By Community Hospital Nurse For Denial of Long-Term Disability Benefits

Gregory Dell — Wed, 09 May 2012 18:27:22 -0500

The Plaintiff, Joni D., with the help of her Alabama Disability Attorney has filed a lawsuit against Reliance Standard Life Insurance Company and the Group Long Term Disability Policy For Employees Of Madison County Community Hospital for the wrongful termination of long term disability benefits.

In Joni D. Vs. Reliance Standard, Plaintiff is suing the Defendants for the unjust termination of her long term disability benefits under the terms of the long term disability plan.

Plaintiff Needed To Use LTD Plan

Plaintiff worked as a Critical Care Registered Nurse, an occupation that required her to perform and fulfill numerous essential job functions, requirements, and qualifications associated with her occupation, including providing direct and indirect patient care, responding quickly and accurately to changes in condition or response to treatment, and performing general nursing duties. Due to her employment, Plaintiff was eligible and partook in the LTD policy that was underwritten by Reliance Standard.

On or about May 5, 2003, Plaintiff became unable to work due to a culmination of disabling physical health issues. These issues were clearly documented in the Plaintiff's medical records. Plaintiff became totally disabled on a permanent basis on or about February 25, 2010. This prevented her from any type of gainful employment as was confirmed by the Social Security Administration as of May 4, 2003. But does receiving disability benefits from the Social Security Administration mean the insurance company will also continually provide long term disability benefits? As Joni came to find out, that answer is no.

Filing of Benefits

Plaintiff filed for LTD benefits on or around November 24, 2003. Reliance Standard agreed to pay the LTD benefits effective October 31, 2003. According to the terms of the Plan, the Plaintiff's condition changed from "disability" to "inability" as of October 31, 2006.

Reliance Standard paid LTD benefits for six years. This included paying the Plaintiff disability benefits under the "any occupation" definition of disability from October 31, 2006 to August 31, 2009.

Reliance Standard Terminated the Benefits Five Times From 2003-2010

On five different occasions, Reliance Standard terminated, denied, or closed the claim between October 31, 2003 and January 7, 2010. This was despite the fact that numerous objective tests showed that the Plaintiff's back pain and radiculopathy continued to exist. The Plaintiff has also continually submitted additional evidence confirming her pain, including medical records and information from doctor visits.

Reliance Standard also improperly handled the Plaintiff's claims over the years, including a time when it claimed that the Plaintiff returned to work even though she never did. It is alleged that Reliance Standard did this to avoid paying the Plaintiff LTD benefits. Despite Reliance Standard's own "quality review unit" claiming that Plaintiff met LTD terms of the Plan and could not handle "any occupation," Reliance Standard continually terminated Plaintiff's benefits until its final termination letter on January 7, 2010.

Plaintiff Files Lawsuit Against Reliance Standard and Group

Plaintiff filed this lawsuit against Reliance Standard because Reliance Standard based its denial on its own "independent" medical examiner's report and attached physical capacity form, even though the two reports contradicted each other and the Plaintiff's submitted medical records and reports. The examiner was also provided through MES Solutions, a biased third party company that has regularly had contact with Reliance Standard, indicating a conflict of interest. Plaintiff also claims that Reliance Standard failed to consider all medical records and other information submitted by the Plaintiff.

Plaintiff Seeks The Following From This Lawsuit

Plaintiff wants the following relief from Reliance Standard and Group:

A de novo review of the Plaintiff's claim for long term disability benefits
All of the past due long term disability benefits
Reinstatement of Plaintiff's claim to all present and future disability benefits so long as Plaintiff is eligible under the LTD Plan
Award of all attorney's fees and expenses
Interest on all past due benefits
All other relief that the Court deems to be just and proper

This Week on DIAttorney.com (05/05/2012)

Gregory Dell — Sat, 05 May 2012 06:28:50 -0500

Disability Blog & Cases:
Eastman Chemical Company Employee Loses Lawsuit Against MetLife for Disability Benefits

In a case recently decided by an Arkansas Federal Court, MetLife prevailed in a lawsuit filed by an Eastman Chemical Company Employee. Ultimately, due to video surveillance, a lack of medical support, and the fact that the claimant had continued working at a side job (of which he had failed to inform MetLife of) while claiming to be disabled, the Court, it seems, had no choice but to agree with MetLife’s decision to deny Long Term Disability Benefits.

Disability Blog & Cases:
Bon Secours Employee Wins Lawsuit Against Unum who had Denied Him Disability Benefits

A former Engineer Director for Bon Secours, with the help of his Pennsylvania Disability Attorney, were forced to file a federal ERISA lawsuit after Unum repeatedly denied his claim for Long Term Disability Benefits under a disability policy he was covered under through his employment with Bon Secours. After filing Cross Motions for Summary Judgment, the Court ultimately ruled in favor of the claimant and against Unum.

Disability Blog & Cases:
Do You Know The Job Requirements To Be A Lincoln Financial Disability Claim Specialist?

As a disability lawyer that has handled thousands of disability insurance claims I often wonder about the qualifications and experience of the disability company employee that is making the decision to approve or deny my client’s claim. During our routine activities of watching The Lincoln Financial Group, I came across an internet job posting for an “Associate LTD Benefit Specialist” at Lincoln Financial in Atlanta, Georgia.The qualifications and requirements for the Lincoln benefit Specialist position are also listed at the end of this article.

Disability Blog & Cases:
A Claimant’s View of a Prudential Disability Benefit Denial

We always welcome our clients and other disability claimants nationwide to share their experiences regarding the handling of their disability insurance claim. A client of our law firm that was denied long term disability benefits by Prudential Insurance Company recently posted her thoughts...

Disability Blog & Cases:
Do You Know The Differences Between ERISA Disability Policy And NON-ERISA Disability Policy?

Watch our video to learn more about long term disability insurance claims which are subject to ERISA.

Disability Blog & Cases:
Will A $38 Million Loss Result In More Prudential Disability Insurance Claim Denials?

Prudential is not very happy right now and disability claimants may suffer as a result. Prudential’s group insurance division, which includes long-term disability insurance policies, reported a 2012 first quarter loss of $38 million compared to a gain of $39, million a year ago...

UnitedHealth Nurse Sues Standard Insurance Company For Refusal To Pay Long Term Disability Benefits

Gregory Dell — Wed, 02 May 2012 17:09:47 -0500

The Plaintiff, with the help of her Massachusetts Disability Lawyer, has filed this lawsuit in the United States District Court against Standard Insurance Company (Standard) for the denial of long term disability benefits as defined by the Plan that the Plaintiff was eligible due to her employment as a nurse with UnitedHealth Group.

The Plaintiff is a 63-year-old resident of Wrentham, Norfolk County, Massachusetts, while Standard is engaged in the business of disability insurance, and is licensed and authorized to engage in the business of insurance within the Commonwealth of Massachusetts. In regards to this lawsuit, Standard engaged in the administration and, in pertinent part, insurance, of the UnitedHealth Group, Long Term Disability Plan.

In Kathleen F Vs Standard Insurance Company, Plaintiff seeks reinstatement of long term disability benefits as defined by the terms of the Plan.

Plaintiff's Background and Reasons For Submittal of Claim

Plaintiff worked as a healthcare utilization review coordinator for UnitedHealth Group, up to and including January 3, 2006. On or about January 3, 2006, Plaintiff was involved in a motor vehicle accident and suffered a right acetabular (hip) fracture. She could not perform the duties of her occupation, or any occupation, due to multiple complications of the healing of the fracture (non-union), as well as severe posttraumatic arthritis secondary to the injury and depression secondary to the injury.

Plaintiff filed for long term disability benefits under the LTD plan. She provided the necessary claim forms, physicians' statements, and supportive medical records. UnitedHealth Group, who funds the first 24 months of benefit payments, approved the claim. This would last through July 2, 2008. After this date, Standard was expected to take over the LTD payments.

Standard Decides To Not Fulfill LTD Payments To Plaintiff

Via letter dated March 31, 2008, Standard denied Plaintiff's claim for disability benefits when it was due to take over payments on July 3, 2008. Plaintiff filed an appeal of this denial, including additional medical support for her claim. However, Standard denied her appeal on July 28, 2008.

Plaintiff was offered, and through counsel, requested an additional level of review by letter dated September 22, 2008. Plaintiff thereafter submitted additional support for her claim, including a recorded video statement on DVD. Plaintiff requested a copy of the complete claim file from Standard on September 22, 2008. Standard did provide some of the requested records, but not provide any of the requested guidelines, policies, or procedures. Plaintiff again requested these relevant documents via letter dated November 27, 2008.

Standard denied Plaintiff's appeal via letter dated April 27, 2009. Standard informed Plaintiff that she has exhausted her administrative remedies. Because of this, Plaintiff has filed this lawsuit against Standard.

Merits of the Lawsuit Against Standard

Plaintiff asserts that Standard did not properly apply the provisions of the LTD plan to her claim. Plaintiff still has not received the requested documents she asked for from Standard. This has denied the Plaintiff her ERISA's statutory right to a "full and fair review" of her claim, as it has prevented her from mounting additional argument in favor of her claim and deprived her of the opportunity to submit evidence that may perfect her claim. This leads to the assertion that Standard breached its fiduciary duties as an ERISA administrator and shows a clear abuse of discretion.

Plaintiff's Relief Requests

Plaintiff wants the following relief from Standard:

Plaintiff has been and continues to be eligible to receive LTD benefits as defined by the terms of the Plan
Standard must pay all disability benefits to which the Plaintiff is entitled to and owed from July 3, 2008 to the present date
All attorney's fees, interest, costs, and disbursements be paid
All other relief that the Court determines to be necessary and just

This Week on DIAttorney.com (04/28/2012)

Gregory Dell — Sat, 28 Apr 2012 06:28:05 -0500

Disability Blog & Cases:
Kentucky Woman Wins Lawsuit Against Mutual Of Omaha Insurance

Claiming that her long term disability benefits were denied improperly under the Employment Retirement Income Security Act of 1974 (ERISA) and 29 U.S.C.§ 1001, et. seq., Nancy C. and her Kentucky disability lawyer filed a disability lawsuit against her employer and disability insurer alleging that the denial of her long-term disability benefits by the insurer was “arbitrary and capricious” and constituted a “breach of fiduciary duty and/or bad faith” on the part of the defendants.

Disability Blog & Cases:
Prudential Claimants Unsuccessful At Challenging The Offsetting Of Dependents’ SSDI Benefit Award

Challenging the calculation that Prudential Insurance Company made when reducing their private benefit payments, Kathleen Schultz and Mary Kelly filed a class action lawsuit in hopes of receiving a positive, definitive decision concerning their claims.

EDAC Technologies Employee Sues Unum for Failing to Provide Long Term Disability Benefits

Gregory Dell — Wed, 25 Apr 2012 17:26:47 -0500

In Jeffrey D Vs. Unum Life Insurance Company of America, the Plaintiff, with the help of his Connecticut Disability Attorney, filed this lawsuit due to the wrongful denial of long term disability benefits as promised under theERISA welfare benefit Plan that is underwritten and insured by Unum.

History of Plaintiff

Plaintiff, who is 46 years old, worked as a machinist at two companies in Bristol, Connecticut for a total of 16 years. He then worked as an Electrical Discharge Machine Operator at EDAC Technologies Corporation (EDAC) in Farmington, Connecticut since 2000. His job required him to position and secure workpieces on a table using clamps; measure parts; manually input data into a computer; and regularly exert between 10 and 50 pounds of force with his hands to move objects.

Plaintiff suffers from gout, a form of severe arthritis characterized by joint pain, tenderness, and reduced mobility in the areas affected. These areas usually include the hands, wrists, feet, and ankles. wrists, feet, and ankles. This medical condition causes him consistent severe pain, occasional complete immobility, and a regular inability to use his hands, wrists, feet, and ankles for almost anything, including grasping, pushing, holding, walking, and standing. His dominant (right) hand and wrist are affected more than his non-dominant hand and wrist. Plaintiff first suffered from gout approximately 20 years, and it has worsened progressively over the years.

Due to the continuing deterioration of his gout, Plaintiff can no longer operate as a machinist or in any other occupation. This has been the case since late-September 2010. Plaintiff takes powerful prescription drugs to combat the consistent pain, but the serious side effects from these medications include lightheadedness, forgetfulness, nausea, and fatigue. These prevent him from driving a motor vehicle or operating other types of machinery and industrial equipment.

Plaintiff filed an application for benefits under EDAC's Unum Plan in September 2010. He was to have received 60% of his "monthly earnings" until a maximum age of "Social Security Normal Retirement Age." According to the terms of the Plan, the Plaintiff satisfied the definition of being disabled both regarding his own occupation (first 24 months of benefit collection) and any other occupation (after 24 months of benefit collection).

Unum Denies Claim

On June 29, 2011, Unum denies Plaintiff's benefit application due to the reason that the medical evidence did not support that his gout was disabling under the Plan's definition; he did not satisfy the Plan's requirement that he work 35 hours per week prior in order to qualify for benefits; and he held another part-time job that he did not disclose to Unum, which disqualified him from benefit collection.

Plaintiff filed an appeal on September 24, 2011 disputing these reasons, which Unum essentially admitted as being true and that it was mistaken in Plaintiff having a part-time job. Plaintiff added 68 pages of medical records, letters from his physicians, Unum's internal claim evaluation notes, and seven sworn records to his appeal.

Plaintiff underwent wrist surgery in fall 2010. His surgeon said in June 2011 that he will have no use of his right hand and wrist, further strengthening Plaintiff's claim that he is disabled under the terms of the Plan. A fusion procedure that is recommended for the Plaintiff would prevent him from undertaking any gainful employment that requires Plaintiff to use his right hand to any significant degree.

Plaintiff also demonstrated that he has done no work for his wife's vending cart business. Plaintiff also showed that he briefly dropped under 35 hours of work per week due to gout flare-ups in his feet.

Despite showing all of this, Unum denied Plaintiff's appeal on October 20, 2011 on the same reasons as its original denial. Due to exhausting all administrative remedies, Plaintiff has filed this lawsuit against Unum.

Reasonings Behind the Lawsuit

Plaintiff claims that Unum's failure to pay these benefits was wrongful, arbitrary, capricious, and otherwise unlawful. Additionally, Unum also chose to disregard the opinion of its own claim reviewer nurse who stated that "it is unlikely that the insured will regain his premorbid level of" functional capacity.

Unum also never requested that Plaintiff undergo an independent medical examination or functional capacity evaluation so that it could attempt to determine the severity of his gout or its impact on his ability to work in his own job or others.

Requested Relief

Plaintiff wants the following relief to be granted by this Court:

Payment of all unpaid monthly disability payments
All prejudgment interest
Costs associated with filing this lawsuit
All appropriate attorney's fees
Reinstatement of Plaintiff's eligibility for continued disability benefit payments in the future
All other relief deemed proper by this Court