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After appeal filed by Attorney Jay Symonds, NWM overturned its previous denial of long term disability benefits for California Customer Relations Supervisor

Attorney Jay SymondsAuthor: Attorney Jay Symonds

Our client, Ms. D, formerly worked as a Customer relations Supervisor in at an Institutional Investments firm. In February 2014 a number of medical issues, including chronic pain, rheumatoid arthritis, Sjogren’s syndrome, Behcet’s syndrome, neuropathic pain, chronic migraine, diffuse connective tissue disease forced Ms. D to stop working and submit her claim for disability benefits under her employer’s long-term disability (LTD) policy, which were funded and administered by NWM. Under her employer’s disability policy Ms. D would be considered totally disabled if she was unable to perform the material duties of her “own occupation” as it is generally performed in the national economy. Material duties are defined as the essential tasks and functions required to perform her own occupation.

After paying Ms. D’s LTD benefits for more than 16 months, NWM denied Ms. D further benefits in September 2015 on the basis that she allegedly no longer met the Policy definition of “Disability.” Specifically, NWM determined that “with the symptoms Ms. D currently has she would be capable of returning to her Own Occupation.” After receiving the denial, Ms. D contacted Dell & Schaefer and discussed his case with Attorney Jay Symonds. Attorney Symonds identified several significant issues in NWM’s denial letter and in the evidence it relied on and agreed to prepare and submit Ms. D’s ERISA appeal with the assistance of his appeal team.

The LTD appeal addressed all of NWM’s short-comings and reasons for denial, with a special focus on the medical records on and around the date of NWM’s denial and significant inconsistencies with its medical reviewer’s findings. In particular, the appeal first addresses NWM’s failure to investigate Ms. D’s ability to perform her own or any other occupation with “reasonable continuity” as required by the Policy. The appeal next addresses NWM’s incorrect determination that Ms. D’s occupation required sedentary level work capabilities rather than light level, which was the correct category. And finally, the appeal addressed the flawed medical review conducted by NWM’s in-house medical consultant, which NWM relied on in denying Ms. D’s continued benefits.

Just over two months later, and after reviewing the appeal and hundreds of pages of exhibits and medical records, NWM overturned its decision to terminate benefits and reinstated Ms. D’s long-term disability benefits.



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