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Appealing a Claim Denial Archives

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."

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.

DI Law Group Appeal Results in MetLife overturning Denial of Benefits for Depression and Anxiety Claim

Our client (Mr. X), a stockbroker in New York, experienced anxiety and major depression as the result of family related issues and the death of his mother after her long battle with cancer. His treating psychiatrist and therapist both advised him to avoid as much stress as possible and take a medical leave of absence from his job in order to focus on his mental health and take the steps necessary to become fully functional. Mr. X submitted the claim forms and physician statements in support of his disability claim and fully expected his disability insurance carrier, MetLife, to pay disability benefits while he was undergoing therapy and until he was functional enough to return to his job. Despite clear evidence of disabling anxiety and depression, MetLife determined that the medical records did not clearly establish Mr. X's limitations or inability to work and denied benefits. He then hired DI Law Group to file the appeal.

Cognitive and Mental Health Conditions Are Not Always Subject to a 24 Month Maximum Benefit Cap

Many group Long Term Disability policies limit the payment of benefit to 24 months if the disability is "due in whole or part to mental illness." However, insurance companies can be quite liberal with this language and apply it to claims where there are cognitive limitations that may have an organic basis or to claims where depression and/or anxiety are a reaction to an insured's physical illness but not actually the disabling medical condition. In a recent 9th Circuit case from California, the Court found that Prudential should not have applied the mental illness limitation to John Doe's claim and ordered Prudential to reinstate benefits retroactively and ongoing.

The First Circuit Court of Appeals Determines that Standard Insurance Company Acted Unreasonably Denying a Claimant Benefits, Where it Failed to Consider the Claimant's Actual Occupational Duties.

In a recent case, the First Circuit Court of Appeals determined that Standard Insurance Company acted arbitrarily and capriciously when it denied an environmental attorney with severe depression Long-Term disability insurance benefits.

Proving Disability from Depression, Anxiety, and other Psychological Conditions

As many insureds suffering from depression and/or anxiety can attest, filing a disability insurance claim based on these illnesses can be complicated and frustrating. Because "objective evidence" of depression and anxiety is not always readily available, these claims are often denied due to a "lack of medical proof" that the insured's condition is severe enough to prevent him or her from working. To be successful at the application level, the insured needs to work closely with their treating psychiatrist, psychologist, and/or therapist to make sure the records (or treatment summary if no records can be provided) reflect concrete examples and clinical information that confirm the diagnoses and the severity of the insured's condition. If psychological testing or neuropsychological testing has been done then that information and the test results need to be included. If the claim has been denied, then it may be necessary to get a detailed statement from each treatment provider as well as testimonial statements from friends, family, and co-workers to submit with the appeal.

A Short Term Disability Denial or Determination Delay Does Not Preclude a Claim for Long Term Disability Benefits

Many insureds are discouraged from pursuing a claim for long term disability benefits prior to receiving an approval of short term disability benefits or after receiving a submitting an appeal of short term disability benefits. A potential problem with simply waiting for the approval of short term disability benefits, especially where the insurance company is dragging out the review process, is that information pertinent to both the short term and long term disability claims is not being submitted and considered by the insurance company and the likelihood of a denial of both claims increases. In the case where short term disability benefits have been denied, submitting an appeal along with a claim for long term disability benefits could very well result in the approval of both.

Disability Insurance Law Group Overturns Cigna's Denial of Disability Benefits in Time for Claimant with Fibromyalgia to Save her Home

Our client, Ms. W, enjoyed a long and successful career as an office manager for a mid-size company. Unfortunately, shortly after receiving a promotion, she began to experience unusual and troubling symptoms such as extreme fatigue, severe pain in her joints, fogginess and confusion, and severe headaches. Originally, she dismissed her symptoms as being run down, a lack of sufficient sleep, and stress. However, overtime, her symptoms progressed and began to significantly interfere with her home and work life. She started missing work due to her fatigue and chronic pain, something she rarely did. She had difficulty concentrating at work, forgot coworker's names and appointments, and lost her train of thought while reading or conducting meetings. She was always exhausted. There were days that she could not get out of her bed and the pain was so severe that it hurt to grip anything, making it difficult to button her shirt, comb her hair, or cook a meal. She often could not walk her dog and had to have a friend come by to help her. Ms. W.'s physicians ran multiple tests, but a diagnosis eluded them. Ultimately, she went to a rheumatologist and was diagnosed with fibromyalgia, through the exclusion of other conditions and positive findings on a tender point examination.

Disability Insurance Denial Answers

Insurance Companies such as Aetna, Assurant, Berkshire, Cigna, Guardian, Liberty Mutual, MetLife, Reliance, Standard, and Unum are well-known for unfair and biased claims review processes, misrepresenting the facts, and for denying valid disability benefit claims. Under the terms of most disability policies and the law, insurance companies are obligated to fully and fairly review each case, engage in proper investigative methods, and timely pay claims to those insureds who are unable to perform the material duties of their occupation and/or any occupation.

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