Administrative Appeal by Dell & Schaefer forces Principal Life Insurance Company to Reinstate ERISA Long Term Disability Claim of Former Healthways, Inc. Employee
Author: Attorney Alex Palamara
After being forced to stop working in 2007 due to various disabling conditions, an employee of Healthways, Inc., who was employed as a Member Care Manager, filed for Long Term Disability Benefits under a policy provided by her employer that was through the Principal Life Insurance Company.
Shortly after applying for LTD benefits, by way of an approval letter dated October 23, 2007, Principal agreed that the Member Care Manager satisfied the terms of the policy and found her to be disabled. Principal commenced payment of LTD benefits effectively on October 20, 2007, after the full completion of Short Term Disability benefits, which were also approved by Principal. The Member Care Manager received LTD benefits from that time and until September 24, 2014.
Unfortunately for the former Healthways employee, such benefits were terminated as of September 24, 2014. By way of a denial letter dated September 30, 2014, Principal informed her that it had “determined that (she was) no longer eligible for (LTD) benefits.” In support of its determination, Principal relied upon an Independent Medical Examination it had commissioned and performed on August 27, 2014. Principal also relied upon Attending Physician Forms completed by her own treating physicians. Principal used this information and concluded that the “restrictions provided by (her doctors) and the IME physician would allow you to perform a sedentary level occupation.” Principal also stated that the “IME did not provide any restrictions for fine manipulation or simple grasping. It also noted that you can continuously reach below your shoulder. It goes on to state that you can occasionally keyboard and use a mouse.” Principal then concluded that with “these restrictions, you are capable of performing the Substantial and Material Duties of your Own Occupation.”
After receiving this denial letter, the former Member Care Manager for Healthways found Attorney Alexander Palamara at Dell & Schaefer. After listening to her and reviewing the denial letter, Attorney Palamara knew that Principal had made an incorrect decision in denying the claim of a 60 year old woman who had been on claim for the previous 7 years and who was suffering from so many serious health conditions. Her conditions included: Chronic Pain, Diffuse Arthralgias, Fibromyalgia, Chronic Fatigue, Rheumatoid Arthritis, Osteoarthritis of the Right Shoulder Joint, Neck Pain, Cervicalgia, Cervical Spine Degenerative Disc Disease, Scoliosis, Lordosis, Bilateral Shoulder Pain, Left Clavicular Joint Separation, Right Shoulder Tendonitis, Back Pain, Spinal Stenosis, Lumbar Spine Degenerative Disc Disease, Lumbago, Bilateral Knee Pain, Bilateral Hand Pain, Bilateral Hip Pain, Bilateral Paresthesia of both Upper and Lower Extremities, Bilateral Carpal Tunnel Syndrome, Left CMC Joint Effusion, Peripheral Neuropathy, Asthma, Shortness of Breath, Granulomatous Disease in the Lungs, Sinusitis, Pure Hyperglyceridemia, Migraines, Insomnia, Urinary Tract Infections, Esophageal Reflux Disease, Vitamin D Deficiency, Myopia, Anxiety and Attention Deficit Disease. Bilateral Parathesisa of both Upper and Lower Extremetries.
Review of the Claim and the Filing of the Administrative Appeal
Shortly after taking on the case, Attorney Palamara received Principal’s entire file which included the Independent Medical Examination report which Principal heavily relied upon to deny the woman’s claim. A review of this report actually showed that Principal’s hired doctor was very supportive that our now client was actually prevented from working. This doctor clearly stated such when he responded to the Principal’s question as to whether there were “any restrictions/limitations applicable which would prevent her from working currently.” The doctor simply acknowledged “Yes.” This doctor who was paid by Principal went further and stated “It is my opinion that there would be very little if any improvement in her condition and very little recovery over time. The rheumatoid arthritis and her conditions of degenerative disc noted on her lumbar x-ray perhaps maybe progressive in nature and therefore little to no improvement in her current functionality is anticipated.”
Additionally, Attorney Palamara also had a chance to review all of the updated medical records as well as those previously provided to Principal. It quickly became crystal clear that Principal’s decision was blatantly wrong and arbitrary and capricious. A timely and proper appeal was filed before the ERISA imposed 180 day deadline. This appeal showed that Principal was arbitrarily picking one liners from its IME report as well as one liners from our client’s medical records. Unfortunately for Principal, this form of review is very improper and it allowed the appeal to tear into and disprove Principal’s earlier conclusions.
Within 60 days of the filing of the administrative appeal, Principal contacted our office and informed us that it was reinstating our client’s claim for disability benefits. It has since paid all back benefits owed and is continuing to pay all monthly benefits timely. We do not foresee Principal denying this claim yet again and we foresee our client receiving full benefits until the policy ends at age 66, her normal social security retirement age.
It is unfortunate that our client had to suffer months without her rightfully owed benefits. However, we are pleased to have taken on her fight and gotten her back on claim. Our client rests assured that Principal will not again play games with her claim as they know that we continue to represent her and will do whatever it takes to keep her on claim.
If you have been denied disability benefits by Principal Life or any other disability insurance provider, please do not hesitate to contact Attorney Alexander Palamara at Dell & Schafer for a free consultation.