J was a 57 year old Director of Engineering for a facilities management company. He sustained a back injury and was awarded both Workers’ Compensation benefits and Social Security Disability benefits. However his claim for Long Term Disability was denied because the carrier stated he could return to his job, which they erroneously classified as sedentary. In reply to our standard demand for the entire carrier’s file, the carrier only provided us with 29 pages. That was obviously not the entire file, something to which we are entitled.
The carrier never explained why they had sent us only a portion of the file, but with what little they did send we were able to show them that J’s job was clearly not “sedentary.” With the additional records we obtained and submitted it was clear that he could not perform his own occupation, the standard for disability under the policy.
Although we never saw the rest of J’s file, J received a check and a letter indicating that his claim was approved.
K worked for an insurance company as a claims representative when she became disabled due to severe depression. Within 24 months of being awarded Long Term Disability benefits, her claim was amended to reflect severe orthopedic problems that prevented her from sitting for any length of time. Despite that, she still tried to maintain some normalcy in her lifestyle, going to the supermarket as needed, socializing with friends when she was able to, and participating in communal activities. She came to us when notified by her carrier that her benefits were being suspended because, based on video surveillance footage, they had determined that she was capable of working.
We immediately demanded a copy of the carrier’s file and had the opportunity to view the surveillance video, and review the medical records that the carrier used to make their determination. The claims file lacked any medical documentation from a treating or examining physician, and in fact didn’t even contain a rationale of how the observed activities could be translated into an ability to perform her job on a sustained basis. Our office contacted K’s physicians, brought the video to their attention, and asked for records as well as comments on whether they felt that K could work considering her ability to do what was filmed. Without exception, each of K’s physicians reported that her orthopedic problems did prevent her from sitting for 8 hours each day and all of them noted that the ability to slowly walk the supermarket aisles as in the video was not incompatible with her medical problem, which was mainly a sitting problem.
Despite these opinions, the carrier suspended K’s benefits. We filed an appeal and it took 6 months for the carrier to respond that additional evidence was necessary (evidence which actually had been furnished with the appeal). After an additional 4 months a denial was issued, with an invitation to file a further administrative appeal. At this point, we had discovered that prior to “investigating” K, the carrier’s representative had been preparing to settle her claim due to the overwhelming evidence that her medical conditions would permanently interfere with her ability to work. Right after the settlement was proposed internally, that claims representative’s name disappeared from the records.
We brought the evidence that had been relied upon to support the initial settlement proposal to the attention of the newest fact finder. We also furnished extensive medical evidence, and we submitted a vocational evaluation that we had had prepared to support our position that while K could occasionally socialize and shop, she was simply unable to sustain any kind of work activity. Finally, 3 years after she first came to us, K’s claim was favorably resolved and the LTD carrier issued her a check for just under $100,000.
M was a very successful medical supply salesperson. An injury to her ankle led to osteoarthritis and made her unable to do her regular work because of the substantial amount of walking involved. The insurance carrier paid M Long Term Disability benefits until her orthopedist circled the “light work” option on one of the carrier’s forms. However, a review of the entire medical record, as well as additional evidence we obtained, showed that the doctor firmly held to the opinion that M could not perform her own occupation.
The doctor apparently had meant “light duty” when he circled the “light work” option on the form. In fact, the only sliver of evidence that suggested M could do her work was the circled item on the form. Everything else that had been written stated consistently that she could not do her job because of the walking necessary.
Once that outrageous distortion of the evidence was made clear, the carrier quickly reinstated benefits with a two paragraph letter and a retroactive payment check.
C had been receiving benefits for several years for numerous physical impairments when he came to us for assistance with his Long Term Disability claim. His insurance carrier had just notified him that they were reviewing his case and that he had to provide updated information about his treating physicians and about his diagnosis and future treatment. The problem was that while C had initially received extensive treatment and surgeries to address his problems, he had not seen his regular physician for several months after having been told that there were no more surgical opinions available and he would have to live with his difficulties.
We recommended that C return to his physician so that, at a minimum, we had documentation of ongoing treatment. We also contacted his doctor and asked very pointed questions about C’s condition to get clarification of his impairment. His regular doctor provided us with the necessary information. In the meantime, C consulted another specialist for a second opinion. That physician made several recommendations for C to explore, including biofeedback and psychiatric care. Upon reviewing those recommendations, his own doctor dismissed them and encouraged that he proceed with a particular form of physical therapy. When we updated the insurance carrier about what the doctors had said, the carrier narrowed in on the recommendations that the consulting physician had made and ignored his own treating doctor’s report. On the basis of that single visit, the carrier notified C that his benefits were being terminated for failure to follow the recommended course of treatment prescribed by his physician.
A flurry of correspondence followed and we were able to extend C’s benefits for a few more months while he commenced biofeedback and psychiatric care as recommended by the consultant. When the extended period of benefits concluded, the carrier notified C that his benefits were to be suspended because he had achieved a level of improvement after undergoing the recommended period of biofeedback and that he was now able to return to his physically rigorous job. Yet contrary to the carrier’s conclusion, there had not been any improvement, and C continued to suffer and remained unable to work. After preparing a comprehensive appeal of the carrier’s determination, we received notice that the carrier agreed with us that our client was in fact disabled, but that due to his psychiatric impairment, his benefits were capped to 12 months after the disability had commenced. There had never been a psychiatric impairment; C’s problems had always been physical and the only reason he even consulted a psychologist was due to the carrier’s pressure. We prepared a second comprehensive appeal of the carrier’s determination and, after over 2 years of appeals, we were able to persuade the long term disability carrier that C’s impairment was physical in nature, that any psychiatric issues he had were as a consequence of his chronic physical problems, that the course of ongoing treatment and medication regimen recommended by his treating physician was proper, and that while treatment might train him to cope with his condition, there was no likelihood of improvement. Ultimately, C was placed back on claim, continues to receive his monthly benefits, and received past due lump sum benefits exceeding $60,000 over the course of his multiple appeals.