Long Term Disability Insurance/ERISA Case Results
Long Term Disability Victory for Chef at the Fourth Circuit Court of Appeals
An Andalman & Flynn client was an Executive Sous Chef for the Hyatt Corporation in San Diego, California when he was forced to stop work in 2004 because of symptoms of osteomyelitis and infection in his spinal cord. He was approved for LTD disability benefits by Hartford. Unfortunately, his condition did not improve despite undergoing surgeries including the implant of a spinal cord stimulator. He had to take prescription pain medication which caused cognitive impairment.
Over the years Hartford had him undergo a Functional Capacity Evaluation and had him surveilled by a private investigator. Each of these evaluations resulted in Hartford continuing to find that he remained disabled.
Per standard operating procedure, Hartford continued to review his claim approximately annually. In 2016, Hartford requested updated information from the treating pain doctor. Unfortunately, the doctor had recently moved and he had been assigned a new doctor. His new doctor advised Hartford that she was unfamiliar with his condition and she requested that Hartford order an FCE (Functional Capacity Evaluation). That FCE was performed by a Ms. Wolf, who determined that despite the fact that he could only sit for about 10 minutes at a time and was likely impaired by medication, that he could perform sedentary work. His treating physician then perfunctorily noted that she “agree[d] with the FCE conclusions”.
Hartford then terminated LTD benefits. Claimant then retained Andalman & Flynn to assist him with an appeal. For the appeal, we obtained an updated FCE as well as a Vocational Evaluation and an Independent Medical Examination (IME), all of which found that he could not perform even sedentary work on a full-time basis. Furthermore, the VE explained why he could not perform a normal amount of work because he had to take breaks approximately every 10 minutes. The appeal explained that the termination was based on the Wolf FCE and that the Wolf FCE conclusion that he could work was inconsistent with its own fact findings. Nonetheless, Hartford affirmed its termination decision following the advice of its doctor who reviewed the file but did not examine the claimant or speak with the treating doctor.
We then filed suit in the United States District Court, as required in ERISA claims. The suit was originally filed in federal court in San Diego, where Shupe had last worked. Unexpectedly, the federal court transferred the case to Virginia, because that is where he was then living. The District Court then upheld Hartford’s termination of benefits.
To his credit, the claimant did not give up. Rather, we appealed to the Fourth Circuit Court of Appeals. Finally, after briefs were submitted and oral argument held, the Fourth Circuit panel unanimously ruled that LTD benefits should be reinstated. The Court found as Plaintiff argued, that the FCE relied upon by Hartford was internally inconsistent and represented an “outlier” in the medical history. Hartford’s termination decision was not consistent with the bulk of the medical evidence, was based upon the faulty FCE, and was issued without ever performing an exam or consulting with a treating doctor.
The Fourth Circuit on December 7, 2021, instructed the District Court to enter judgment, including reinstatement of benefits from the date of termination, over 5 years ago. It has been an enormously difficult five years for our client, but we are thrilled that he will finally be reinstated with back pay.
Successful Appeal of Long Term Disability Termination for Client with Fibromyalgia
A Long Term Disability (LTD) beneficiary retained our services to appeal the termination of their LTD benefits. Our client held a white-collar management position at a major pharmaceutical company. Client last worked in 2012 in a position that was reduced to part-time hours as an accommodation for the severity of symptoms from fibromyalgia. Client was awarded and received LTD benefits for close to eight years. Client also was found disabled by the Social Security Administration. Nonetheless, the LTD carrier informed the client in the Spring of 2020 that they were no longer eligible to receive benefits because they no longer met the definition of disability (the inability to perform any occupation).
The termination decision was based on two medical reviews and an employability analysis performed by the carrier. There was no examination of the beneficiary and the beneficiary’s treating doctor continued to report that our client remained disabled. We helped our client obtain additional medical evidence as well as a Functional Capacity Evaluation and psychological/cognitive and vocational testing which documented that our client continued to exhibit debilitating, chronic total body aches and pain caused by fibromyalgia as well as major depressive disorder, generalized anxiety disorder, mild neurocognitive disorder, sciatic nerve pain, and knee pain.
The documentation and argument submitted on appeal by attorneys Elliott Andalman and Matthew DeGioia resulted in the reversal of the termination decision and the reinstatement of LTD benefits.
Long Term Disability (LTD) Claim Settled in Full
Elliott Andalman settled a Long Term Disability (LTD) client’s claim and obtained complete reinstatement LTD benefits, including the full payment of back benefits! This case involved a complicated back and forth with the insurance carrier during the administrative appeal stage. Every two or three work, Elliott was forced to provide rebuttal evidence to the carrier’s file review physician, even after filing the formal administrative appeal. Andalman & Flynn did excellent work developing the record so that by the time this claim reached Federal Court, the carrier was forced to give in. In addition to paying all the claimant’s back benefits, the carrier was forced to place the claimant into pay status going forward.
Successful Long Term Disability Claim for Client with Mental Impairment
Like most LTD policies, our client’s policy had a two year limit on benefits paid for disabilities caused or contributed to by a mental impairment. This client came to us after their benefits were terminated based on the mental impairment limitation. However, this client had severe pain as a result of a back injury as well as a mental impairment. We appealed the termination and collected documentation to establish that the physical disability was disabling regardless of the client’s mental impairments. Our appeal was successful and our client remains in pay status to date.
LTD Success during the Second Level Voluntary Administrative Appeal
Attorney Peter Casciano successfully appealed CIGNA’s 2018 decision to terminate his client’s long-term disability benefits, which she received due to post-fusion surgeries, migraines, and fibromyalgia. After unfairly receiving a denial on the initial administrative appeal, we did not give up and crafted a compelling second-level appeal, which resulted in CIGNA’s reversal of their denial and reinstatement of his client’s benefits retroactive to July 2018. Also, the claimant was awarded ongoing disability benefits so long as she remains disabled in accordance with the LTD policy’s definition of disability.
Successful Long Term Disability Claim for Client with Severe Back and Knee Problems
A 55-year-old woman retained our services to prosecute an application for Long Term Disability (LTD) benefits. The client was presenting symptoms of severe arthritis in both knees causing her to limp significantly, along with major back problems including degenerative disc disease with disc bulges. Complicating matters for our client was her inability to tolerate major pain medicines such as oxycodone and tramadol…
Long Term Disability (LTD) Claim Settled for Over $800,000.00
Peter Casciano and Elliott Andalman have just settled a Long Term Disability (LTD) client’s claim in full for a total settlement of over $800,000.00! This was a significant win for the client for several reasons. First, the client’s claim was denied on initial application. Mr. Casciano and Mr. Andalman were able to successfully appeal this denial and produced medical…
Blue Cross Concedes Health Insurance Coverage for Hospitalized Client
This client retained our services to appeal a denial of insurance coverage for a psychiatric hospitalization. Blue Cross Blue Shield (BCBS) claimed that the hospitalization, which was for over two months, was not considered medically necessary. We obtained the entire medical record from the hospitalization,…
Successful Disability Claim for Client with Chronic Fatigue
This client retained our services to appeal a denial of Long Term Disability (LTD) benefits. Basis of disability is profound fatigue. The carrier claimed that records did not include specific restrictions and limitations on why the client could not work nor were diagnostic tests provided. Benefits…
Continued Success for Claimant Subject to Long Term Disability Insurance Review
Client retained our services for claim for Long Term Disability (LTD) and Social Security Disability (SSD) benefits. Claimant has had both hips replaced and has low back pain, and osteoarthritis. The claim for LTD benefits was awarded on initial application but with initially three-month reviews….
Attorney Elliott Andalman Wins Disability Appeal for Client with Multiple Sclerosis
This client retained our services to appeal termination from Long Term Disability (LTD) benefits. Basis of disability is Multiple Sclerosis (MS). The LTD carrier terminated benefits based on a single office visit note from treating neurologist indicating that the client had an excellent exam. It required…
Disability Appeal Won for Client Suffering from Lupus
A client retained our services to appeal termination from Long Term Disability (LTD) benefits. Basis of disability is lupus. Benefits were terminated because the client’s treating doctor reported that her condition had stabilized and also based on the client’s ability to travel to visit her sick parent…
Success on Long Term Disability Claim Improperly Filed by Employer
The client retained our services to appeal a denial of Long Term Disability (LTD) benefits. Basis of disability is osteoarthritis of the right knee for which client underwent a total knee arthroplasty. A significant hurdle in this claim was that the benefits manager at the client’s company never properly…