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Disability Insurance Law Blog

Pro athletes may face disability insurance claim fights

At our law firm, we represent professional athletes in their claims for disability insurance. Pro athletes are of course at higher risk than most people of serious work injury because of the dangerous nature of high-level athletic performance on a regular basis. Whether disability results from one severe mishap or accident in the course of a game, match or performance; from ongoing, repetitive motion or movement; or from something unrelated to sport participation, we advocate for our athlete-clients to recover their rightful disability insurance benefits.

Social-media surveillance of disability claimant’s activities

We recently posted information in this space about how disability insurers use surveillance to investigate the lifestyles of their disability claimants to try to uncover evidence that the claimants’ activities are inconsistent with the medical conditions underlying their disability claims. In other words, a video of a claimant mountain climbing might suggest they are not disabled from congestive heart failure.

But usually the cases are much more controversial than that. For example, is looking happy at a family party evidence the person is not severely depressed? That kind of picture is commonly available on Facebook or other social media sites. As we have explained, many insurance companies now use electronic surveillance techniques, including the use of social-media monitoring.

Insurers use of drones in surveillance of disability claimants

When you are ill or injured to the point where you had to file a claim for disability benefits under your disability insurance policy, it can be disheartening to learn that during the initial review process or even while on claim that your insurance company put you under surveillance. You filed your claim in good faith, expecting fair and reasonable treatment; instead, your insurer used some form of surveillance to “catch” you being active.

Policy language limits disability insurer administrator's power

A recent court opinion sheds light on the ramifications of disability insurance policy language that describes what powers the insurer's administrator has to decide claims. We recently posted a blog about the standards of review courts apply when considering an appeal of an insurer's disability claim denial under the Employee Retirement Income Security Act, usually called ERISA.

ERISA is the federal law that governs most group and/or employer-supplied disability insurance plans. ERISA establishes minimum standards for these policies to help protect the rights of individuals they insure.

Court uses de novo standard of review when insurer blew deadline

A federal appeals court decided that because a disability insurance plan administrator missed a strict ERISA deadline for issuing a benefits decision on review, the correct standard for the court reviewing the denial of benefits to use is "de novo" rather than "arbitrary and capricious."

In most ERISA claims, when the ERISA Plan delegates discretionary authority to the Plan Administrator to interpret plan provisions, then a denial of benefits is reviewed under the "arbitrary and capricious" standard. This means that the court will only overturn the insurer's decision if the Plan Administrator acted unreasonably or outrageously in the process it used to deny the claim. Basically, this gives significant deference to the insurer's exercise of its discretion under the plan to decide the claim.

What is a disability insurer's structural conflict of interest?

A large insurance company that sells short- or long-term disability coverage can intimidate an individual fighting for their rightful benefits after having become disabled. When that insurer decides its own claims internally, rather than outsourcing that decision-making process, it has a structural conflict of interest.

This means that although it's claims examiners are supposed to make decisions on disability claims reasonably, fairly and according to policy terms and applicable law, the examiners may feel pressure to deny claims. In an approved claim that very insurance company must then pay out benefits, sometimes for years, and sometimes at a high rate.

Female soccer players and disabling brain injury

At DI Law Group, we represent professional athletes in their claims for long-term disability insurance often based on debilitating mental or physical injuries. Obviously, professional sports are not gentle on bodies or brains and disabling injuries can prevent a pro athlete from continuing to earn a living in their sport. In severe cases, these injuries might keep them from working even in less strenuous jobs.

In those cases, it is appropriate for them to file claims for disability insurance benefits. Disability insurance for pro athletes might be provided through their team employers or professional sports associations, or they may purchase private disability insurance policies. Disability insurance companies are motivated to deny elite athletes’ claims because they can be very expensive if their payouts are based on previous income levels.

Court holds LTD claimant did not have a pre-existing condition

On Sept. 3, the U.S. Court of Appeals for the 1st Circuit held that Aetna had wrongly denied long-term disability insurance coverage to a claimant with malignant melanoma. The opinion turns on a legal issue that comes up often in LTD cases — whether the claimant had a pre-existing condition that invalidated his disability claim.

Man with severe heart condition denied disability by Cigna

When Florida residents have a medical disability that keeps them from working, they often depend on their disability insurance to help them financially survive. Unfortunately, insurance companies sometimes refuse to pay, leaving people between a rock and a hard place. Such is the case with a Chicago man.

According to a recent news report, the man was forced to leave his job as vice president of a magazine due to a debilitating heart condition. After he suffered two heart attacks, underwent a five-way bypass procedure and continued to experience chest pains, his doctor told him he was permanently disabled and his career was too stressful to safely continue. However, when he filed a claim for long-term disability benefits with Cigna, the insurance company denied his claim three times, arguing that his desk job wasn't stressful enough to threaten his health.

Work-related injuries may qualify for short-term and long-term disability benefits

Injuries that occur on the job may be compensated through a workers' compensation claim. However, injuries that result in a prolonged absence or even permanent disability may qualify the employee for benefits under their employer's short-term disability and/or long-term disability plans.

The thought of not being able to work but still having financial obligations can be frightening and overwhelming. Workers' compensation only goes so far. Understanding the benefits and rights provided under a short-term disability and/or long-term disability policy may provide the insured with the means to cover their expenses while unable to work.

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