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Chiropractor Obtains Lump-Sum Disability Insurance Settlement Despite Wrong Date of Disability

Attorney Cesar GavidiaAuthor: Attorney Cesar Gavidia

Caution, the timing of a disability claim can mean the difference between having your claim approved or denied. Far too many times I have seen disability insurance claims denied because the claimant either failed to promptly file their disability claim, mistakenly adopted the date which the insurance company claimed their disability began or state an inaccurate date of disability on the initial application for benefits. The claimant’s date of disability is crucial in determining: 1) what the claimant’s “Own” or “Regular” Occupation is; 2) how long the claim could be paid; and 3) if the claim will be paid.

When The Claimant Purchased His Disability Policy He Was Gainfully Employed As A Chiropractor

Our client, Dr. Z, had attended college and trained to become a chiropractor. When he purchased his individual disability insurance policy with Metropolitan Life Insurance Company (“MetLife”), he had recently begun working as a chiropractor and his duties consisted of performing manual chiropractic adjustments on patients. Dr. Z soon successfully grew his practice and was operating 4 different chiropractic offices.

Generally, the definition of “own/regular occupation” in an individual long-term disability policy (Non-ERISA) means the usual occupation (or occupations, if more than one) in which you are Gainfully Employed at the time that you become disabled. This means that the disability insurance coverage should follow you from occupation to occupation, and will not be limited to only covering the occupation that the insured is performing at the time that the disability insurance policy is purchased.

Metlife Denies Disability Claim Of Chiropractor Due To Change In Occupation Prior To Date Of Disability

Dr. Z began experiencing bilateral pain in his knees and feet, and would experience difficulty walking. It was discovered that Dr. Z suffered from complex regional pain syndrome. He continued working in his practice, but was eventually forced to close most of his offices due to the pain and discomfort he experienced especially when treating patients. At around this time, Dr. Z also began teaching part-time for a local university and working as a Residual Functional Capacity/Vocational Specialist for the Social Security Administration. Dr. Z also notified MetLife that he had become disabled from performing his duties as a chiropractor, however, on his application for disability benefits he provided MetLife with a date of disability which followed the date that he began working for the university and the social security administration.

MetLife had Dr. Z’s claim reviewed by a physician consultant who determined that Dr. Z would indeed have restrictions and limitations from running, jump, climbing stairs, standing, stooping and kneeling, and perhaps even performing the duties of a chiropractor. However, MetLife determined that although Dr. Z had these restrictions and limitations, he was not disabled under the terms of the policy since he was continuing to work and could work in his teaching and vocational consultant positions. Dr. Z was shocked and could not believe that his claim was denied, as it was his belief that he should be paid since he could no longer perform his regular occupation as a chiropractor.

Dell & Schaefer argues that Dr. Z’s regular occupation was his occupation as a chiropractor, the usual occupation (or occupations, if more than one) in which he was Gainfully Employed at the time that he become disabled.

Following his denial of disability benefits, Dr. Z consulted and retained Cesar Gavidia and Dell and Schaefer to represent him in his disability claim with MetLife. Following several meetings, a review of the claim documents, medical records, and financial records for Dr. Z’s chiropractic practice, it was determined that Dr. Z had chosen an incorrect date of disability. Dr. Z had assumed that his date of disability was the date he completely discontinued seeing patients, when, in fact, his date of disability should have been stated as being even earlier – when he began reducing his patient volume and duties, and before he began working as a vocational consultant and teacher. MetLife was notified of the incorrect date of disability, but they were not willing to change their determination.

MetLife was provided with the opportunity to correct Dr. Z’s date of disability and pay his disability claim; however, it continued to deny that he was eligible for disability benefits. Following several weeks of negotiations, which included threat of suit by Dr. Z, attorney Gavidia negotiated a confidential settlement between Dr. Z and MetLife.

Dr. Z’s case is a perfect example of why the timing of a disability claim and the actual date the insured claims disability are so important. In Dr. Z’s case, claiming total disability 12 months earlier meant the difference of thousands of dollars, and the difference between his claim being approved or denied. As in Dr. Z’s case, most disability policies state that the claimant is disabled from the occupation or occupations that they are performing at the time that disability begins. It is important to carefully analyze how and when the claimant’s disability began affecting their ability to work and generate income.

Contact us for a free consultation to discuss how we can assist you with your disability insurance claim. For more Metlife disability cases and user reviews please click here.



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