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Fort Lauderdale Florida Insurance Law Blog

Disability Approval by MetLife and Guardian Berkshire for Doctor with Neck and Back Pain

DI Law Group was hired by Dr. Brown to assist him with his claim for disability benefits under both the group policy procured for him by his professional medical association and the private disability policies he took out on his own. While Dr. Brown was certainly still functional and able to exercise and live his life, due to significant neck and back pain, particularly while in the bent over positions he was required to sustain during examinations and procedures, he could no longer properly and effectively perform the duties of a medical doctor.

Partner Alicia Paulino-Grisham was Selected by American Conference Institute to Speak at the Annual American Conference Institute: Litigating Disability Insurance Claims Conference

On February 22, 2018, the American Conference Institute ("ACI"), one of the leading organizations on educating the insurance industry, conducted its annual National Advanced Forum on Litigating Disability Insurance Claims. Alicia Paulino-Grisham was again invited to participate as a Speaker.

Important Tips for Appealing an ERISA Disability Insurance Denial

A denial of disability insurance benefits too often comes as a surprise to individuals who file legitimate claims and are genuinely unable to competently perform their job duties with reasonable continuity. Making the decision to apply for disability insurance benefits is difficult; but when one determines that it is necessary, most individuals who have paid for these policies or are covered by a group policy expect the insurance company to fairly and objectively review their claim and pay the disability benefits to which they are entitled under the policy terms. Unfortunately insurance companies are not always inclined to timely review claims and pay the benefits owed under the policy. This is true for individual disability insurance policies (those taken out and paid for directly by the insured) and group policies (those procured by an employer as a benefit of employment or through a professional group/association). The focus of this blog is appealing the denial of group policies that fall under the Employee Retirement Income Security Act of 1974 (ERISA). It should be noted that filing a detailed and thorough appeal where a denial has been issued under an individual or group policy is extremely important; however under ERISA claims an appeal is required before a lawsuit can be filed and litigation is primarily limited to the information in the claim file at the time of the final denial.

Lincoln Financial Group Buys Liberty Life Assurance Company for $3.3 billion

Lincoln Financial Group has announced that it has entered into an agreement to acquire Liberty Life Assurance Company of Boston from Liberty Mutual Insurance Company for $3.3 billion. The acquisition is expected to be completed in the second quarter of 2018. With this acquisition, Lincoln Financial is posed to become number one in combined fully insured disability sales market share in the group benefits area, as well as third in the combined total life and fully insured disability sales market share. It is not yet clear when the full transition will take place, whereby current Liberty Mutual customers will be dealing directly with Lincoln Financial.

The Department of Labor Implements New Regulations to Increase the Protections Afforded to Disability Insurance Claimants

Section 503 of ERISA requires employee benefit plans to provide written notice to any participant or beneficiary whose benefit claim has been denied, and to provide the claimant a full and fair review of the claim. Despite these protections, claimants face an uphill battle in attempting to overturn wrongfully denied claims. On December 16, 2016, the Department of Labor ("DOL") announced the release of a final rule to strengthen consumer protections for workers making claims for benefits under their workplace group disability insurance plans. The final rule was to apply to claims submitted after January 1, 2018. However, after significant complaints from the insurance industry alleging, without any factual underpinnings, that the final rule would increase the cost of disability insurance, decrease workers' accessibility to the coverage, and cause a surge in litigation, the DOL announced on November 4, 2017 that it was delaying the implementation of the final rule by 90 days. The DOL allowed the insurance industry to provide data to support its claims and permitted claimants' advocates an opportunity to respond. The DOL was flooded with comments from claimant advocates explaining the necessity of the final rule. In contrast, the DOL found the "data" produced by the insurance industry underwhelming and determined that it simply did not support its allegations. Accordingly, the final rule will go into effect April 1, 2018.

Traumatic Brain Injury LINA Claim Denial Reversed and found to be Arbitrary and Capricious

In the case of Van Steen v. Life Insurance Company of North America ,WL 256806 (10th Cir. Jan. 2, 2018) the Tenth Circuit, affirmed the district court's decision, finding that Life Insurance Company of North America's decision to terminate Mr. Van Steen's benefits was arbitrary and capricious. Mr. Van Steen was diagnosed with mild traumatic brain injury as the result of a physical assault. Initially he was prevented from working in any capacity. However, he was eventually cleared to return to work on a part time basis; but with noted limitations including the ability to rest frequently and work from home as necessary. At the time of his disability, Mr. Van Steen was employed by Lockheed Martin Corporation which provided disability coverage under the Lockheed Martin Group Benefits Plan. The short term and long term disability plans were both administered by Life Insurance Company of North America (LINA) and controlled by the Employee Retirement Income Security Act (ERISA).

Court Ruling on Mutual of Omaha Pre-Existing Denial of Benefits

In the case of Horneland v. United of Omaha Insurance Company, the eleventh circuit reversed the United States District court for the Middle District of Florida's decision finding for the defendant. In the case, Horneland sued United of Omaha Life Insurance Company under ERISA, due to the fact that United of Omaha Life Insurance Company denied Horneland's long term disability. Horneland began to work as a real estate manager for Thornton's Inc. as part of the employment, Horneland received short term and long term disability coverage. However, per United of Omaha Insurance Company's insurance plan, long term disability coverage begins on the day following completion of 12 months of Active employment. The long term disability benefits also include a Pre-existing conditions exclusion. That exclusion states that the insurance company will not provide benefits for disability (a) caused by, contributed to by, or resulting from a Pre-existing Condition; and (b) which begins in the first 12 months after the individual is continuously insured under the policy. The eleventh circuit defines the term pre-existing as any injury or sickness for which the individual received medical treatment, advice or consultation, care or services including diagnostic measures, or had drugs or medicines prescribed or taken in the 3 months prior to the day they become insured under the policy.

A Federal Court Overturns AETNA's Termination of Total Disability Benefits to a Claimant, finding that AETNA'S decision was Arbitrary and Capricious.

In a recent case, Patterson v. Aetna Life Insurance Company, No. CV 15-8156, 2017 WL 4786562 (D.N.J. Oct. 23, 2017), the United States District Court for the District of New Jersey, determined that Aetna's termination of Christopher Patterson's Long Term Disability Benefits was arbitrary and capricious. Mr. Patterson was employed by First Consulting Group, Inc. ("FCG"), which provided Long Term Disability Benefit coverage to its employees under the Long Term Disability group policy (the "LTD Policy"). The LTD Policy provided that disability occurs when an employee is unable to perform the material duties of their "own occupation" solely because of the disease or injury; and when the employee's work earnings are 80% less of their adjusted pre-disability earnings.

Attorney's Fees Granted for Sedgwick Arbitrary and Capricious Denial

In the case of Corey v. Sedgwick Claims Mgmt. Servs., et al., No. 1:15 CV 1736, 2017 WL 4844008 (N.D. Ohio Oct. 26, 2017), the Sixth Circuit remanded the case to the administrator for a "full and fair review." In this case, the Plaintiff was an employee for Eaton Corporation. As an employee, he was entitled to participate in the Corporations Disability Plan for U.S. Employees. The plan states that a participant is eligible for short term disability benefits if an illness, whether occupational or non-occupational, prevents them from performing the essential duties required for the job. In addition, the plan states that the participant would need to provide verification from a health care practitioner proving, that due to the disability, they will not be able to perform such duties. The plan requires, for both Short Term and Long Term Disability Plans, that the participants provide objective findings of disability. That is findings that their health practitioners observe through objective means, not the participants own description of the symptoms.

DI Law Group Successfully Resolves Cardiac Claim against Disability Insurance Co.

When our client, an attorney, originally hired us to help his with his ERISA long-term disability insurance claim, his claim for disability benefits had already been denied. He had been diagnosed with a cardiac condition and advised by his cardiologist to reduce stress and change his lifestyle in order to prevent further heart damage and possible heart failure. In keeping with his doctor's orders, he took on a less strenuous legal role in the law firm where he worked and significantly reduced his hours. After the filing of an appeal and then a lawsuit, the denial was ultimately reversed and our client continued to work in the reduced capacity prescribed by his physician and the insurance company paid his benefits for many years.

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