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Fort Lauderdale Insurance Law Blog

Why was the insurance claim for my eating disorder denied?

It took far too long for the medical community to realize that eating disorders require the same attention, compassion and treatment as any other disease or disorder. It took even longer to understand that there is more than just a physical component to these disorders. Those affected also need psychological support as well.

Even though insurance companies may provide benefits for both the physical and mental aspects of recovery, they may be separate under a policy. This could present a challenge when making a claim since many case managers do not understand the need for both aspects of care. For this reason, you may find yourself facing a denial of benefits.

Prepare to battle for coverage of eating disorder treatment

Without a doubt, you have had some frightening moments in the recent past. Perhaps you have sat in an emergency room on more than one occasion or called for an ambulance for your unresponsive loved one. Certainly, you had more than one argument with your child, an argument that ended in you tearfully pleading for him or her to just eat something.

While it may be difficult for you to understand the motivation behind your son's or daughter's refusal to eat, what is not difficult to understand is that your child needs help. You likely did research into the numerous Florida area treatment centers for eating disorders, and you found a place that agreed to treat your child. Now the question is whether your insurance will cover the claim.

Prudential Denies Disability Benefits based on Severance Agreement

The case Thomas v. The Prudential Insurance Company of America, 2018 WL 211 118020, US Dist. Ct. E.D. Pennsylvania, is a reminder of how important it is to understand the implication and consequences of all terms in a severance agreement. When drafting a severance agreement to be signed by a departing employee, employers include broad language designed to protect them as well as their agents, affiliates, fiduciaries, etc. from any future claims or liabilities, whether known or unknown. The result is that by signing the agreement and taking the severance payment, an employee may forever waive their right to legitimate claims or benefits which arose prior to their termination date.

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).

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