We represent individuals, including physicians, nurses, and other medical professionals, when they have to litigate against their long term disability insurance companies. The situation usually starts when the individual has been on disability and then receives a letter from the insurance company stating that for various reasons the person is no longer considered to be “disabled’ as that word is defined in the insurance policy.
Often the long term disability denial is based on a review of the medical records by a physician retained by the company. That doctor simply reads the medical data and then opines that the insured person is not disabled because, for instance, there is a lack of objective evidence of disability, there are only subjective complaints. Or, the doctor reads the records and says that while the insured person is not capable of doing whatever job he/she was doing, they are physically fit enough to do some other type of work that will pay them a certain percentage of the income they were making at their original employment.
This opinion by the physician is then reviewed and relied upon by an employment specialist who will state that there are certain types of work available in the area where the insured person works, and those jobs pay enough to take the insured person out of the definition of being “disabled”. With these two arrows in the quiver, the insurance company representative then writes the “denial” letter which simply says that the review of the records shows that the insured is capable of a certain level of work and that there are employment opportunities available in the area which pay the required amount of money. Accordingly, no more disability payments will be made. Have a good day.
The denial letter will also advise that you can appeal this decision within, typically, 180 days. Of course, this appeal is to the same insurance company that decided you are now not “disabled” and therefore this is, obviously, a challenging adventure. We suggest that at this point, you do not attempt to do this appeal by yourself. The reason you should leave this to someone who has experience is that you normally only get one chance at reversing the denial and if you forget to put in critical documents or do not make certain types of arguments, you may well have made it impossible to reverse the decision. The crux of the problem is that if you lose this appeal and then go to federal court to force the insurance to restart the payment of your benefits, that court can only review the documentation that is in the insurance company’s file. You are not permitted to add any additional medical records, expert opinions, photographs, test results, or anything else that might help your case. In other words, you must know precisely what information has to get into that appeal to the insurance company because if you leave out one crucial piece of evidence you will not be able to later make up that deficiency.
For example, we very recently won an appeal for a registered nurse who had been denied benefits on the ground that she was not disabled as per the definition of that term in the insurance policy. Among other things, we retained
the services of our own occupation specialist and he wrote a lengthy analysis of the matter which proved that this nurse, at her age, and with her cardiac issues could not possibly be able to do the work that the insurance company maintained she could do.
So, if you have been denied benefits for long term disability, you might give us a call to see if we can help you regain those benefits.
