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.
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.
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.
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.
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.
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.
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.