Our client, Mr. E, formerly worked as a Sales Representative for a domestic beverage distributing company. In July 2016 a number of medical issues, including the debilitating effects of Lumbar Intervertebral Disc (IVD) Syndrome with radiculitis to his bilateral extremities forced Mr. E to stop working and submit his claim for disability benefits first under his employer’s short-term disability (STD) policy and then continuing under its long-term disability (LTD) policy. Both benefits were funded and administered by Lincoln National (Lincoln). Under his employer’s disability policy Mr. E would be considered totally disabled if he was unable to perform the material and substantial duties (i.e., main duties) of his own regular occupation. Material duties included, among other things, those job tasks normally required to perform his occupation and could not reasonably be modified.
After paying Mr. E for 1 week under the Policy’s “own occupation” definition of disability, Lincoln denied continued LTD benefits on the basis that he allegedly no longer met the policy definition of disability. Specifically, Lincoln stated that “the medical documentation contained in [Mr. E’s] file does not support continued Total Disability.” After receiving the denial, Mr. E contacted Dell & Schaefer and discussed his case with Attorney Jay Symonds. Attorney Symonds identified several significant issues in Lincoln’s denial letter and in the evidence it relied on and agreed to prepare and submit Mr. E’s ERISA appeal with the assistance of his appeal team.
The LTD appeal addressed all of Lincoln’s short-comings and reasons for denial, with a special focus on the medical records on and around the date of Lincoln’s denial and significant inconsistencies with its medical reviewer’s findings. The appeal next addressed Lincoln’s contention that ongoing disability was not supported because it alleged “there was no active treatment.” However, Mr. E’s primary treatment provider’s Attending Physician’s Statement (APS) clearly established that Mr. E’s condition as of the date Lincoln ceased payments was disabling – which Lincoln agreed – and expected to continue for at least 6 months or more. And his subsequent treatment sessions in March and May 2017 not only confirmed The APS’s medical opinion but establish that Mr. E’s condition had, in fact, deteriorated. Consequently, Lincoln’s attempt to justify its denial by claiming that there was “no active treatment” mischaracterized the record evidence and was not the result of a full, fair, thorough and honest investigation of Mr. E’s claim.
Just over four weeks later, and after reviewing the appeal and hundreds of pages of exhibits and medical records, Lincoln overturned its decision to terminate benefits and reinstated Mr. E’s long-term disability benefits.