Before you submit an appeal of your group short-term ("STD") or long-term ("LTD") disability claim, it is essential that you understand your obligations and rights under the applicable law. What you do not know, could hurt you!
Almost fifteen years ago, Unum Provident entered into a historic multi-state settlement with 3 lead states, 46 other states and the District of Columbia, as well as the U.S. Department of Labor, that cost it in excess of $120 million to comply, required it to reassess claims it has denied dating back to 1997, and called for an additional $15 million in fines. Maine Superintendent at the time, Alessandro Iuppa, was quoted by the Insurance Journal as saying, "This action is one of the most significant multistate insurance regulatory actions in history, providing a uniform, verifiable and effective state-based settlement for the benefit of UnumProvident policyholders nationwide." But did the over $135 million paid by Unum and the substantial, extensive corrective action and requirements of Unum under agreement, along with risk of another $145 million or more in fines, deter UnumProvident from continued bad faith claims handling?
A recent case out of the North District of Oklahoma, Anderson-Posey v. Unum Life Ins. Co. of Am., involved a long-term disability insurance policy issued by Unum Provident and governed under the Employee Retirement Security Act of 1974 ("ERISA").
A federal district court recently overturned Northwestern Mutual's denial of own occupation disability insurance benefits to an attorney with congestive heart failure unable to handle stress. The case Mustain-Wood v. Northwestern Mututal Life Insurance Company involved a family law attorney and partner at his own law firm who experienced congestive heart failure requiring major surgery and cardiac rehabilitation. 938 F.Supp. 2d 1081 (D. Co. 2013). Mustain-Wood became unable to practice as an attorney in part because of the high stress environment it required.
Ms. A became a kindergarten teacher in 2001. She loved her job and each of the children she taught throughout the years. Unfortunately, in the winter of 2014, Ms. A. was in a serious car accident. She was stopped at a light when a pick-up truck struck her car from behind going approximately 45 miles per hour. Her car was propelled into an intersection and struck by another vehicle on the driver's side. Ms. A broke her pelvis, left hip, left leg, and left arm and shoulder. She had multiple surgeries and was in the hospital for several months. She was unable to return to her class room for the rest of the school year and had to undergo physical therapy throughout the summer. Ms. A hoped to be able to return to work the following year. However, despite the surgeries and physical therapy, Ms. A remained in constant and overwhelming pain. She had difficulty walking unassisted and could not sit, stand, or walk for prolonged periods of time. Even minor activity increased her pain to intolerable levels. It became clear that Ms. A would never be able to return to the classroom. As such, Ms. A applied for long-term disability benefits under the terms of her Metropolitan Life ("MetLife") Disability Insurance Plan. After a long investigation, MetLife ultimately approved Ms. A's claim, finding that she met the definition of Total Disability as she was "unable to perform the duties of her Regular Occupation" as a kindergarten teacher. Subsequently, MetLife required Ms. A to apply for Social Security Disability Income ("SSDI") benefits and she was ultimately determined by the Social Security Administration to be unable to maintain gainful employment in any occupation. In accordance with Ms. A's MetLife policy provisions, MetLife began deducting the full amount of Ms. A's SSDI benefits and her young daughter's dependent SSDI benefits from each of Ms. A's monthly MetLife disability benefit checks and required her to pay all back benefits received from the Social Security Administration to MetLife.
Our client, Mr. D was a partner at a large accounting Firm for 9 years. Unfortunately, he began to experience severe and debilitating symptoms and was ultimately diagnosed with Multiple Sclerosis ("MS"). Mr. D had difficulty accepting the diagnosis and sought a second and third opinion. Unfortunately, both physicians confirmed that he suffered from MS. As reality set in, Mr. D fell into a deep depression. With the help of his family, his therapist, and his MS specialists, Mr. D overcame his depression and focused on his family, his work, and maintaining his health.
Chiropractic Physician, Joan Hangarter, owned her own chiropractic practice in Berkeley, California and during a typical day she would treat between 30 and 50 patients. In 1989, Dr. Hangarter purchased an "own occupation" disability insurance policy from Paul Revere. Unfortunately, in 1993, Dr. Hangarter began to experience severe recurrent shoulder pain, which progressed to ongoing severe pain in her shoulder, arm and neck that interfered with her ability to treat patients as a chiropractor. Although Dr. Hangarter underwent significant treatment, her condition did not improve. After imaging was performed, she was diagnosed with epicondylitis, cervical intervertebral disk syndrome, and tendinitis. Though Dr. Hangarter's orthopedist offered surgery to correct the problem, Dr. Hangarter declined given her past negative experience with post-surgery pain medication. Dr. Hangarter did continue with chiropractic treatments which gave some pain relief. Dr. Hangarter's doctors advised and testified that she could not maintain a normal, continuous chiropractic occupation in light of her medical conditions.
There is a great deal of misinformation about the amount fraud against disability insurance carriers. While some people may believe going out on disability is akin to an early retirement, those individuals who are truly disabled know this is certainly not the case and that few sane people would jump through the insurance company hoops to earn significantly less than they earned while working. Moreover, most individuals do not want to be considered disabled as they took great pride in their work and ability to earn a living. At DI Law Group, we represent numerous clients who reluctantly faced their disability and depend on their disability policy coverage to provide them with some income while they remain unable to work.
In the case of Giddens v. Equitable Life Assurance Society of the United States, 445 F.3d 1286 (11th Cir. 2006), the Eleventh Circuit Court of Appeals held that regardless of his intent, if Dr. Giddens was not practicing dentistry at the time of his disability under his policy, dentistry was not his "regular occupation" for purposes of his disability claim. Under Dr. Giddens' disability income policies, in order to receive total disability benefits he was required to be unable due to injury or sickness to perform substantial and material duties of his regular occupation. The policies further defined "regular occupation" as "the occupation (or occupations, if more than one) in which you are regularly engaged for gain or profit at the time you become disabled." Dr. Giddens' position in the filing of his disability claims was that he had dual occupations - both dentistry and real estate development - and that he was disabled from both. However, Equitable contended that Dr. Giddens had abandoned his dentistry practice years prior to his disability claim filed in 1999, and thus that his dentistry disability claim should not be permitted. The Court ultimately agreed with Equitable and disallowed the dentistry disability claim on the basis that it was no longer Dr. Giddens' regular occupation at the time of his disability in 1999.
The type of disability insurance policy that you have may affect your rights and obligations under the contract and law. Typically, disability insurance policies will fall into one of three categories, based on how the policy was obtained: private, group, or association. It is important to understand what type of policy you have before pursuing a claim or attempting to fight a delay or denial of your benefits.