After Initially Being Denied Long Term Disability Benefits, Dell & Schaefer Gets Former Wal-Mart Employee on Claim with Liberty Mutual
Author: Attorney Alex Palamara
A former employee of Wal-Mart contacted our firm on March 11, 2015. She informed us that she had recently been diagnosed with Multiple Sclerosis less than a month earlier. She also informed us that prior to this diagnosis she was forced to leave her occupation as a Personnel/Training Coordinator for Wal-Mart Stores, Inc. She previously had been diagnosed with small fiber peripheral neuropathy, ankylosing spondylitis and migraine headaches. Unfortunately for this very nice lady, her body left her unable to perform the material and substantial duties of her own occupation. Thankfully her employer Wal-Mart provided its employees with the Wal-Mart Stores, Inc. Associates’ Health and Welfare Plan. This plan provided a Long Term Disability (LTD) policy in case such a situation arises where a person as a result of injury or sickness is unable to continue to work. This plan would provide a percentage of her prior monthly earnings if she should qualify.
Even though her doctors had yet to fully diagnose what was occurring with her body, she figured she should surely qualify because her body left her unable to work. She timely filed an application for LTD benefits with Liberty Mutual, but this application was denied by way of a letter dated September 30, 2014.
The ERISA statutes provide that a person has a right to challenge a denial of such benefits by filing an administrative appeal. The ERISA statutes also give a 180 day deadline to file such an appeal. If an appeal is not timely filed, then the person who made the claim will lose their rights under the policy and be prevented from filing a lawsuit for this claim. In other words, filing a timely appeal is an ultimate necessity.
When this former employee of Wal-Mart contacted us on March 11, 2015, there was only 18 days remaining to file this timely appeal. Attorney Alexander Palamara quickly got involved and requested a copy of the administrative record from Liberty Mutual and also requested a 60 day extension of time to submit the appeal. Luckily, by way of a letter dated March 24, 2015, Liberty Mutual approved this request and gave us some breathing room to file the appeal. Now it must be noted that not all insurance companies will afford such an extension of time and such requests are often denied. So although this case turned out positive and Liberty Mutual gave us the requested extension, it cannot be stressed enough that no one who has been denied benefits should wait to contact our firm for representation as sufficient time is needed to draft the strongest appeal possible.
Review of the Claim and the Filing of the Administrative Appeal
In its initial denial dated September 30, 2014, Liberty Mutual relied upon a clinical review and assessment of a Board Certified Physical Medicine and Rehabilitation Physician. Based on the medical records that were previously provided by our now client, this physician opined that “physical impairment is not supported by available records…”. Unfortunately for our client, although she was suffering severely, she did not provide sufficient “proof of loss” to prove her case with Liberty Mutual.
As mentioned earlier, since the time of this initial denial letter, our now client had a new diagnosis and better understanding of why she was suffering from visual, motor and sensory problems as well as fatigue and chronic pain. Because of her diagnosis of Multiple Sclerosis and the accompanying restrictions and limitations she was suffering from, we knew that Liberty Mutual had to overturn its decision if we were able to show objectively through her medical documentation that she was unable to perform the material and substantial duties of her own occupation.
Complete medical records were ordered from all of her treating physicians. We also asked certain physicians to complete Attending Physician Statements which we drafted specifically for this client. A review of the medical records showed objectively that Liberty Mutual should be paying LTD benefits.
A timely appeal was filed May 22, 2015. This appeal provided all the compiled medical records and proved objectively that Liberty Mutual must approve this claim. Thankfully, Liberty Mutual Agreed. By way of a phone call on June 18, 2015, Liberty Mutual informed Dell & Schaefer that it was approving her claim under the “own occupation” definition of disability and that it would be paying her claim for the full year that it previously should have been paying.
Although the policy makes it more difficult to qualify for LTD benefits after the initial year (at that point, one must be unable to perform the material and substantial duties of any occupation), Dell & Schaefer will fight to prove to Liberty Mutual that our client should also qualify under the new definition of disability. Should Liberty Mutual deny her claim under this standard, Liberty Mutual knows that it will have a fight on its hand as Dell & Schaefer will continue to do whatever it takes to keep her on claim until her policy expires or until she is ready and able to return to work.
If you have been denied disability benefits by Liberty Mutual or any other disability insurance provider, please do not hesitate to contact Attorney Alexander Palamara at Dell & Schafer for a free consultation.