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Can my insurance carrier deny my benefits even if there is no change in my medical condition?



Attorney Rachel AltersAuthor: Attorney Rachel Alters

Insurance companies frequently terminate long term disability benefits after paying a claim for several years, even when the claimant’s condition remains the same. It would seem unfair that one’s benefits can be cut off when their disabling condition has not improved or changed in any way. However, it is quite common that a person who has been on disability for several years, who has been approved for “any occupation” benefits will receive a denial letter that their insurance carrier no longer believes that the medical documentation supports disability, when in fact nothing has changed.

In the recent case of Buss v. United of Omaha Life Insurance Company, the Court determined that United of Omaha, also known as Mutual of Omaha, acted arbitrary and capricious when it terminated Buss’s claim when there was no new evidence to support their position that he was no longer disabled. The Court noted that Buss’s complaints of pain were consistent with MRI and X-Ray evidence and that none of the updated medical information reviewed by United of Omaha to approve benefits for many years showed any improvement in his conditions. The Court stated, “Determining a person to be disabled one day and not disabled the next day upon review of the same information fits the very definition of arbitrary.” Unfortunately, this type of behavior is common practice for insurance companies looking for any reason to deny benefits. Fortunately for this plaintiff, and future plaintiffs in similar situations, the court did not let Untied of Omaha get away with this arbitrary termination of benefits.

Although an insurance company can deny a claim for any number of reasons, a denial of benefits based on medical records that indicate no improvement in one’s medical condition is clearly an arbitrary and capricious denial of benefits. Attorneys Dell & Schaefer did not represent Buss in this action, but if your claim has been denied or you are worried that your insurance carrier may deny your claim based upon a faulty medical review please feel free to contact us to discuss how we may be able to assist you.

There are 8 opinions so far. Add your comment below.

Becky J.:

I carry Long and short term disability from the Harford, through the company I work for. In May 2014 I had my second non-cancerous brain tumor removed. The first brain tumor was removed in Oct of 1990. This second brain tumor was 2.5 bigger than the first, therefore my disabilities, are more severe.

I did not qualify for SSDI, because it is based on income/assets.

Therefore Social Security (in Oct 2014) opted to give me SSI rather than SSDI. I hadn’t planned to start drawing my social security benefits until I was 66. (Because the payment is when I am 66 is greater than what I received as a 64 year old).

Without even waiting for the medical papers from my Drs, the Hartford this month (Feb 2015) reduced the LTD I had been receiving from them, by 384.00.

It is my understanding, Social Security benefits does not have the 6 month “wait” time as the SSDI requires. So do I have the right to challenge social Security as well, since they did not back pay me to April (2014) when my second brain tumor was found?

It is my hope to be able to go back to work, but presently I am not able to walk, have trouble talking, walking, and have numerous issues (i.e. memory problems, and other brain surgery, related issues as well.

I may have already contacted you on this issue, if so, I apologize.

Attorney Stephen Jessup:

Becky,

You can certainly appeal the SSDI decision, and I would advise that you do so. With respect to the Hartford offset- is it due to an estimated SSDI offset? They should have documented and explained same to you. Please feel free to contact our office to discuss your claim further.

S Hollingsworth:

I have been receiving LTD for two years. I just received a form requesting financial information. Why do they need this information and is this a normal process?

Attorney Stephen Jessup:

S. Hollingsworth, requests for financial information are common. Most carriers will send them periodically to make sure all sources of potential offset are accounted for.

Chris:

If someone is on an own occupation IDI claim for several years and after a few years on claim loses their professional license because of the physical illness (inability to practice due to physical impairment, not psychiatric problems or substance abuse and certainly not due to legal or disciplinary issues), if the insurance company would abruptly terminate the claim after paying for years with no change in medical condition, how can they justify that the patient can return to their specialized own occupation if they can’t perform it due to both an unchanged physical illness and license loss CAUSED by the disability they were paying for?

Do they just try to claim that the physical illness magically went away and it’s not their problem if the license was lost during the disability claim? How do they expect the claimant to get their license back to return to their own occupation?

Or do they use the license loss as the reason to terminate the claim because now it’s a “legal disability”?

I guess I can believe the insurance companies would try almost anything to stop paying, but isn’t that bad faith?

Attorney Stephen Jessup:

Chris, most policies will indicate that loss of a professional license is not, in and of itself, does not constitute a disability. Although the physical medical condition prevents you from maintaining the license (and the ability to work in your profession) the carrier’s typically try to argue that the medical information does not support the inability to perform your occupational duties so in turn the loss of your license is not enough for you to be disabled. That’s the spin – now that’s not to say that will hold up. Please feel free to contact our office to discuss your claim in greater detail.

Chris:

I guess it’s lucky that his policy is an older one that doesn’t exclude loss of professional license in the contract language, so they’d at least not have that specific exclusion argument to make. If nothing changed medically from the month before when they paid benefits based on the same information they used to deny benefits the next month, then short of some ungodly damning surveillance video, they really don’t have a good leg to stand on, do they? I’ll let him know to get in touch, thanks.

Attorney Stephen Jessup:

Chris, at the end of the day it will always be the medical information that will carry the most weight. Please feel free to contact our office to discuss further.

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