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."
Surveillance is a frequent tool used by disability insurance companies to try to deny or terminate claims. We often hear from claimants: "I have nothing to worry about, because I am actually disabled. Let them follow me;" "I would know if I were under surveillance;" and "my claim is not worth enough for my disability insurance company to pay to surveil me." Unfortunately, these common misconceptions about insurance company surveillance all too often result in claimants being stunned that their truly deserving claims have been denied or terminated.
By Maggie Smith of DI Law Group:
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, 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.
While many insured's believe that medical evidence of a disability is enough to obtain disability benefits from their disability insurance carrier, this unfortunately, is not the case. A successful disability insurance claim begins with the application process . The information contained within the application for benefits is essential, and if insufficient, can cause extensive delays in the approval of the claim or even a denial of the claim for benefits. The following case is typical of the delays and difficulties experienced by many of our clients who applied for disability benefits on their own.