Insurance companies often deny benefits based on an inability to complete a preexisting condition investigation without any consideration to the merits of the disability claim. Unfortunately, an insurance company’s inability to complete a preexisting investigation is often due to its own mismanagement of the claim file and lack of due diligence.
Prior to becoming disabled, our client worked as a Police Officer for the Metropolitan Police Department (Government of the District of Columbia). Unfortunately for our client, after being involved in a motor vehicle accident and suffering from ongoing back, neck, and shoulder pain, he was denied benefits based on the insurance companies alleged inability to complete its preexisting condition investigation. The Standard denied the claim despite acknowledgement by its medical reviewer that limitations and restrictions were in place that would prevent our client from performing the duties of his own occupation.
Like most group disability insurance policies, our client’s insurance policy provides an exclusion for preexisting injuries which states that there is no coverage for a disability that is caused or contributed to by a preexisting condition. When our client filed his claim, the Standard initiated a customary investigation into any preexisting conditions which included a request for certain pharmacy records and records from a certain physician regarding a recommended diagnostic test.
Unfortunately for our client, despite providing the Standard with the release for the pharmacy records and advising the claims handler that he never underwent the recommended diagnostic test, his claim was denied.
Alexander Palamara of Dell & Schaefer Files Appeal
After speaking with the client, it was readily apparent to Attorney Palamara that the Standard’s decision to deny benefits was incorrect. It was clear that our new client was not capable of performing the material duties of his own occupation, he did not have a preexisting condition, and the Standard’s denial for being unable to complete its preexisting condition was improper, likely a mismanagement of the claim investigation.
After gathering The Standard’s claim file and updated medical records from our client’s treating physicians, an administrative appeal was drafted to challenge the denial. Our appeal highlighted the errors in the handling of the preexisting condition investigation, presented all of the information necessary for the Standard to complete its preexisting condition investigation, and presented all of the medical information supporting our client’s restriction and limitations.
A few months after the appeal was filed, our client, was approved for benefits and continues to receive benefits to this day. Although our client was without benefits for nearly a year, he is happy to be on claim. He also knows that he can trust Dell & Schaefer to keep him on claim until he is able to return to work or until his policy expires.
If you have been denied disability benefits by the Standard or any other disability insurance company, please do not hesitate to contact Attorney Alexander Palamara at Dell & Schafer for a free consultation.