Our now client was a dedicate employee of Vienna Beef who worked as a Customer Service Representative (a sedentary occupation) since August 2013. Our client was a dedicated employee as she enjoyed the job and loved her employer. Unfortunately for our now client, medical issues seemed to be piling up and they began to affect her ability to perform the duties of her own occupation.
The Former Customer Service Representative had a list of various diagnoses which included Fibromyalgia, Hypoglycemia, Osteomyelitis, Venus Insufficiency, Headaches, Fatigue and Myofascial Pain. When taken globally, her ability to work was clearly severely impacted. Thankfully, her employer provided its employees with disability insurance coverage. Thankfully, that coverage was with Principal.
After initially stopping work in January of 2018, our client applied for Short Term Disability (STD) Benefits under her employer’s STD policy. After a thorough review, Principal approved her STD claim and commenced payment of benefits which were paid fully through the expiration of the STD policy. Her claim was then submitted for review and approval under the Vienna Beef Long Term Disability (LTD) Policy. Thankfully, the LTD claim was approved with benefits beginning in May of 2018. Benefits were ultimately paid for a total of 24 months, through May 1, 2020.
Unfortunately, continued benefits beyond May 1, 2020 were denied as this coincided with the date that the “change in definition of disability” occurred. What this means is that under the LTD policy governing this claim, what it means to be disabled changes after 24 months. This is very common for Policies employees have coverage under by way of their employers. Typically, for the first 24 months, in order to qualify for benefits, one must be unable to “perform the majority of the Substantial and Material Duties of his or her Own Occupation.” However, after 24 months, in order to continue to receive LTD benefits, at that point, the claimant must then prove that he or she “cannot perform the majority of the Substantial and Material Duties of any occupation for which he or she is or may reasonably become qualified based on education, training, or experience.”
It was at this “change in definition of disability” when Principal decided to deny further benefits and this decision to deny continued benefits was conveyed via a denial letter dated April 30, 2020. Through this letter, Principal explained that following its review, it found that “The information we reviewed supports you can perform other occupations, which means you aren’t eligible for LTD benefits after 5/1/2020.” It later stated that it actually believed that our client was “able to perform (her) Own Occupation as a Customer Service Representative.” Thus, not only were they denying the claim due to the change in definition of disability, but now they were saying that she actually had the ability to perform her old job, despite the fact that they had just paid disability benefits for 24 months because they had previously determined otherwise.
In support of its decision to deny benefits, Principal mostly relied upon a stale paper review dated February 19, 2019 by an “independent” Internal Medicine and Endocrinology doctor. Beyond that review, there were a few reports of Principal nurses, but nothing strong enough to support Principal’s contention that our now client could perform any occupation or her old occupation.
Alexander Palamara of Dell & Schaefer Files Appeal
Knowing that there was no way that she could return to any occupation and knowing that this denial was wrong, the former Vienna Beef employee found Dell & Schaefer and worked with Attorney Alexander Palamara. After a review of the old and updated medical records as well as a review of Principal’s Claim File, it was clear that Principal’s decision was wrong and without sufficient justification or support. A timely appeal was filed and the appeal focused on a few things, including: 1. The staleness and deficiency of the “independent” physician’s review and opinion; 2. The lack of support for Principal’s decision; 3. The objective evidence which supported our client’s diagnoses and symptoms; and 4. The support from each of the treating providers who each agreed that there was no way that their patient could perform her own or any occupation.
Although it took some time, in early 2021 we finally got word the Principal was righting its wrong and overturning its decision to deny benefits. A few days later, a large check for benefits owed from 5/1/20 to the present arrived and we forecast that many additional checks will continue to arrive as our client remains disabled. Our client knows that we will work hard to make sure her claim is never denied again and to ensure that her benefits remain approved until she is age 67 or has the ability to return to work.
If you have been denied disability benefits by Principal or any other disability insurance company, please do not hesitate to contact Attorney Alexander Palamara at Dell & Schafer for a free consultation.