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Disability Insurance Law Blog

Liberty Insurance forced by Court to pay LTD Benefits for Anxiety and Bipolar Disorders

In May 2015, Wells Fargo & Company (Wells) hired Rosa Ramirez as a Financial Crimes Specialist. Shortly thereafter, in August 2016, Ms. Ramirez stopped working at Wells after suffering a mental breakdown following an altercation with her manager. Thereafter, due to her worsening depression and anxiety since starting her new job, Ms. Ramirez applied for short-term disability benefits and in September 2105, Liberty Life Assurance Company of Boston (Liberty) approved her claim. Later in December 2015, Ms. Ramirez was diagnosed with Bipolar Disorder, Post-Traumatic Stress disorder, Anxiety and Major Depressive Disorder. Additionally, her treating physician opined that she required a high level of care given the severity and chronicity of her mental illness. Accordingly, Ms. Ramirez was referred to Daymark Recovery Services (Daymark). Shortly thereafter, Ms. Ramirez had her initial assessment and despite some initial improvement Ms. Ramirez regressed and under her doctor's recommendation, filed a claim with Liberty for long-term disability benefits (LTD benefits) and was approved in March 2016. In May 2016, however, Ms. Ramirez' condition worsened as she began to experience violent thoughts and act abnormally. Accordingly, Liberty re-reviewed Ms. Ramirez' claim and extended her disability benefits through July 31, 2016 because she was unable to perform nothing more than activities of daily living. In August 2016, Ms. Ramirez' doctor completed Liberty's restriction form due to her condition.

A disability insurance claim denial need not be the last word

Having insurance coverage can provide peace of mind. The hope, of course, is to never have reason to file a claim, but the expectation is that if a loss occurs, the insurance company will respond in a timely manner, address the issue professionally and pay an appropriate settlement amount to cover the damages incurred. However, when it comes to disability insurance claims, many Florida claimants find that the reality of how the insurance company handles the matter is far different from their expectations.

Although there are three different types of disability insurance an individual can have, legal experts report a high incidence of denial of benefits from all three. For both Social Security disability and employer-provided disability insurance, which is governed by federal ERISA laws, the right to appeal a denial is guaranteed. Where private disability insurance is involved, most allow some form of appeal, but it will be necessary to verify this by reviewing the specific language and terms of the contract.

What to do if your private insurance benefits are denied

If you are a private insurance policyholder in Florida, you have a right to file a valid claim should you need insurance benefits for a specific purpose related to your policy - e.g., a car accident, flood or theft. But if you have a claim that's denied, you have a legal right to attempt to collect payments you believe you are entitled to receive. This process involves filing a breach of contract claim against your insurance company. Before this step is taken, however, many insurance policies and state insurance laws require policyholders to make a demand for payment directly to the insurance company.

If you skip the demand for payment step, you may not be able to take additional actions related to denied private disability claims in the future. This is why it's best to review your insurance contract to understand the provisions that apply to your situation. It's not unusual for claims to be initially denied simply because the required documents weren't submitted, or deadlines were missed. In situations like this, denials may be overturned once the correct information is given to the insurance company.

DI Law Group Appeal Results in Cigna/LINA Overturning Denial of Benefits for Lupus and Fibromyalgia Claim

Our client (Ms. X), a director of credit and collections in New York, hired DI Law Group to assist with her Long-Term disability claim with Cigna. She was diagnosed with Fibromyalgia, Lupus, Encephalopathy, Migraine headaches, Chronic Fatigue, Sleep Apnea, Chronic Pain Syndrome, Lumbosacral Disc Disease, Sciatica, and secondary Anxiety as well as common side-effects of prescribed medications affecting her cognition. Ms. X was having great difficulty at work and was making mistakes and unable to physically or mentally perform the material duties of her occupation. Ms. X's treating doctors executed Attending Physician Statement forms advising that Ms. X is unable to perform the material and substantial duties of her regular occupation. However, Cigna initially denied the claim. DI Law Group submitted an appeal on behalf of Ms. X and argued that Cigna made unfounded credibility determinations, cherry-picked the medical records, ignored the claimant's subjective complaints, and unduly delayed rendering a decision by requesting medical records previously submitted to Cigna. Ultimately, Cigna/Life Insurance Company of N. America (LINA) overturned the denial of benefits and approved of Ms. X's long-term disability claim.

Claims for long-term care insurance benefits

In Florida, your claim for long-term care benefits is governed by your long-term care insurance policy. If you're no longer able to care for your needs on your own and need to go into a long-term care facility, it's important to obtain a complete copy of your insurance policy prior to filing a benefits claim.

There are strict time limits that you must follow to notify your long-term care insurance company about your need for long-term care. You also must file a proof of claim for benefits within a time period that will be determined by your policy. The insurance company must then respond within a certain time period and send claim forms to you. You will need to submit enough evidence that proves your need for benefits or your claim will be denied.

Disability Insurance Company Claim Reviews - What Are They Looking For?

Throughout the time claimants are eligible for disability benefits and benefits are being paid, claimants are intermittently advised that their claim is being reviewed and that updated information is required. This often indicates that the insurance company is scrutinizing the claim to see if there is evidence that can be used to suggest that the insured has improved enough to return to work. These requests for updated medical information may be made directly to the insured's treating physician(s) who do not have time to draft a detailed response to the numerous questions on the form being sent to them and/or who do not have the time to speak with the insured's consulting physician, who tends to call during peak business hours. Updated records are requested from doctors and the insured receives forms to complete. In certain cases, the insurance company has conducted surveillance and seeks additional information from the insured and their doctor(s) in order to obtain "clarification" about the activities seen on surveillance and the insured's reported limitations.

ERISA Disability Insurance Appeals - Appealing A Long Term Disability Denial

Individuals who receive short term disability and long term disability coverage as a benefit of their employment are often shocked when their insurance carrier unreasonably delays the review and approval of a claim or unjustifiably denies or terminates their disability benefit. Despite a legitimate claim and medical proof that their illness or injury prevents them from working, many insureds find themselves holding a letter from their insurance company explaining that, based on its review of the claim, the insured is not disabled and benefits are therefore denied or terminated. The letter often contains incorrect information about the insured's health; it tends to omit important information and facts; and the carrier very often points to the opinion of a "consulting physician" who read the medical records and attempted (insincerely) to contact the insured's physician as the basis for the denial. Upset, scared, and frustrated, the insured appeals the denial without fully understanding their rights and "rules of the game". Unfortunately, not understanding the appeals process and what must be included to overcome a denial of benefits in an ERISA claim puts the insured at a disadvantage. Moreover, the failure to appeal within the 180 day deadline may prevent the insured from further pursuing their right to these benefits.

Aetna Denial Overturned due to Failure to Conduct a Full and Fair Review

Those who have filed insurance related claims have experienced the outcome-driven assessments in which insurance companies typically partake to determine an individual's disability. A recent federal court case, Gorena v. Aetna Life Insurance Company ("Gorena"), is a prime example. Gorena was presented before the court on Ms. Gorena's Motion for Summary Judgment. Ms. Gorena sought to order Aetna Life Insurance Company ("Aetna") to approve and pay her long-term disability claim. In this case, the US District Court for the Western District of Washington at Seattle found that the denial of Ms. Gorena's disability claim was wrongfully determined because Aetna misrepresented and ignored Ms. Gorena's sufficient evidence which established her inability to perform her occupation.

Defining bad faith as it relates to insurance claims

Insurance companies in Florida and throughout the country are required to act in good faith in investigating and paying out policy claims. However, bad faith is defined differently depending on where the claim is made. In some cases, a bad faith action by an insurance company is a tort whereas it could be considered a breach of contract in other instances. In a tort case, a policyholder must show that benefits were withheld and that doing so was unreasonable.

Depending on the facts of such a case, negligence alone may not be enough to show that an act was taken in bad faith. In showing that benefits were withheld, it may be necessary to prove that a claim was valid and that it was actually denied by the insurance company. It is possible that state law determines whether an action is deemed to be in bad faith.

Debilitating PTSD makes living nearly impossible for some people

Many Florida residents experience traumatic events. Some of them are able to deal with the situation and move on with life within a reasonable amount of time. However, others cannot move on from the trauma quite to so easily. They tend to bear the scars from the event for a significant amount of time and to the point where it takes over normal life.

If you feel this way, you more than likely suffer from post-traumatic stress disorder. You may hear PTSD thrown about by people for seemingly trivial issues. They do so because they don't realize how debilitating this condition can be in the aftermath of a traumatic situation. If you suffer from PTSD, you may often hear from others that you "should just move on" from what happened. Those people just don't understand the depth of your distress.

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