Our client, Mr. D, formerly worked as a Trucking Supervisor for a large steel distribution center. For many years Mr. D suffered from chronic debilitating effects of multiple physical conditions and ailments, including severe degenerative osteoarthritis and cervical spine multilevel degenerative disc disease, which left him with debilitating physical impairments. Mr. D was unwilling to give up his career and worked as long as he possibly could. As a result of his serious medical conditions and associated restrictions and limitations, Mr. D was forced to stop working in June 2016 and apply for disability benefits under his company’s Short and then Long Term Disability (LTD) Policies, both of which were administered and funded by Lincoln.
Lincoln found Mr. Dougherty to be totally disabled and approved his STD claim through the 13 week maximum benefit period which ended in September 2016. With the expiration of the STD benefits Mr. D’s claim was submitted for continued payment under Lincoln’s LTD Policy, with the same definition of disability. After paying his LTD benefit for 21 months Lincoln terminated benefits because claiming Mr. D could now perform his prior “heavy” occupation. Mr. Dougherty filed a timely appeal that was unsuccessful. Following a successful second level appeal, benefits were extended only for the balance of the own occupation period to September 2018 as Lincoln determined that Mr. D could perform other gainful occupations. After receiving the denial, Mr. D contacted Dell & Schaefer and discussed his case with Attorney Jay Symonds, who identified several significant issues in Lincoln’s denial letter and in the evidence it relied on and agreed to prepare and submit Mr. D’s ERISA appeal with the assistance of his appeal team.
The appeal addressed all of Lincoln’s short-comings and reasons for denial. First, the appeal detailed the results of a February 2020 FCE attended by Mr. D specifically for his appeal. The FCE objectively quantified his maximum physical functional capacity. With regard to sitting, standing and walking the FCE confirmed, among other restrictions, Mr. D had the ability to sit for 40 minute intervals, stand for 30 minute intervals and walk for 10 minutes intervals. Based on the findings in the FCE Mr. D would be unable to perform work in the sedentary physical demand level due to his inability to sit for 2 hours at any one time, stand and/or walk up to 2 hours, work an 8 hour workday, nor repetitively use his lower and upper extremities. The FCE findings were then reviewed and adopted by Mr. D’s primary care physician.
The Appeal Challenges Lincoln’s Medical Consultant
Next the appeal addressed the purported opinions of Lincoln’s medical consultant. More specifically, the consultant’s opinion relied, in part, on his belief that Mr. D could perform modified occupations, which was clearly outside the scope of his role as a medical records reviewer. Whether an occupation is available to be performed on a modified basis and whether an employer is willing to modify a particular occupation to accommodate employees is for a Vocational Consultant to determine, not a medical consultant. What’s more, the consultant was not board certified in a specialty relevant to Mr. D’s complex medical conditions (e.g., an Orthopedist) but rather as a physical medicine and rehabilitation physician, did not physically examine Mr. D prior to rendering his opinions and his conclusions were contradicted by the objective finding throughout Mr. D’s medical records.
And finally, the appeal addressed Lincoln’s failure to meaningfully review and consider Mr. D’s Social Security Disability Award, which Courts have repeatedly found instructive when determining whether a carrier conducted an unreasonable investigation. More specifically, the appeal argued that Lincoln’s conduct raised serious questions about whether its denial was the product of a principled and deliberative reasoning process or Lincoln’s financial conflict of interest due to its role as both the funding source and decision maker.
A Swift Decision by Lincoln
Just 6 weeks after filing his appeal, and after reviewing hundreds of pages of exhibits and medical records, Lincoln overturned its decision to terminate benefits, paid full LTD back benefits and reinstated Mr. D’s LTD benefits. Attorney Symonds continues to represent our client to best ensure that Lincoln will not terminate his benefits again. Feel free to call our disability attorneys for a free consultation regarding any matter relevant to your disability claim.