This case is unique and a valuable lesson for all of those receiving LTD Benefits. Prior to Dell & Schaefer getting involved with this claim, our now client worked as a Computer Programmer for ACI Worldwide. She was hired by her employer in April of 1986 and worked there all the way through December of 2005. Unfortunately for her, she suffered from viral vestibular neuritis which led to vestibular nerve damage. The accompanying symptoms of her conditions prevented her from continuing at any employment. Luckily for her, her employer provided a Long Term Disability (LTD) Insurance Policy should she be unable to work. After filing a claim for benefits, her claim was approved and benefits commenced in March of 2006. These benefits continued until May 30, 2017, when unexpectedly, the former Computer Programmer received a letter from Lincoln advising her that her benefits were being terminated. Utterly confused on why this was happening, the former computer programmer contacted our firm and spoke with Attorney Alexander Palamara.
After hearing her story, Attorney Palamara knew that Lincoln’s actions in this claim did not smell right. It made no sense for her to be denied after 11 years as her condition did not improve and Lincoln had not requested updated medical records in some time. Pouncing on this claim and agreeing to work with the former computer programmer, Attorney Palamara first ordered a copy of all the records that Lincoln possessed on this case. In a typical case, after a person is on claim for 2 years, an average claim file should be around 2,000 pages. If a person is on claim for 10+ years, the claim file should be a few thousand pages at the very least. When Attorney Palamara received the claim file he initially thought Lincoln failed to provide the entire document or misunderstood his request. The claim file provided was merely 359 pages. Once the attorney reviewed the file he came to the understanding that this was in fact the entire claim file. He also came to the realization that for the last 11 years, Lincoln had done next to nothing on this case. This lead to the question: If Lincoln did next to nothing on this case, why was it now denying the case with no true justification to do so?
A review of the Claim File
A review of the claim file showed the story of how Lincoln first acted wrongly. After initially approving her claim in 2006, on April 3, 2008, Lincoln made a decision to refer this claim to its “Mature Claims” category. This apparently meant that Lincoln understood that this claimant would be disabled for some time and that requesting updated records and forms from her was unnecessary as no change was expected. Lincoln essentially went into a hibernation mode on this claim and only ended up requesting the claimant to complete “Supplementary Statements” every even numbered years. No updated medical records were requested and thus no updated medical records were provided by the claimant. The claimant believed Lincoln to be satisfied as she always timely and fully complied with their requests.
Unfortunately, the rug was pulled out from underneath the claimant and her claim was denied by way of May 30, 2017, denial letter. In support of its decision to deny benefits, Lincoln solely relied upon the results of an Independent Medical Examination of April 6, 2017, which was performed by Dr. Pamela SantaMaria. Of course Dr. SantaMaria made findings that Lincoln used to deny continued benefits. The doctor stated that “There is nothing in the medical records presented for my review nor in my exam of Mrs. Falk to support a functional limitation at this time.” Well of course this was true as Lincoln’s file had no medical records from 2008 forward and Dr. SantaMaria was only provided records from 2006-2008. Her examination was in April 2017! Even Dr. SantaMaria felt something was odd here as she noted that she “would however like to reserve the right to change that determination if new information is brought forth to support a functional impairment and the need for restrictions and limitations.” In all our years of reviewing IME’s and independent file reviews, we have never seen a doctor state that he/she would like to reserve the right to change their determination. And of course Dr. SantaMaria stated she found nothing in her exam. But in this claim, no doctor would expect to find anything during an exam of this client as when it comes to dizziness, the physical exam is most often normal. Furthermore, any tests done are relatively insensitive to finding causes or even displaying dizziness as being present and it is common for patients to have severe problems and have these tests be entirely normal. In this sense, Vestibular issues are unique and Lincoln’s Claim Examiner was unaware of such.
Appeal by Attorney Palamara
An administrative appeal was timely and properly filed by Attorney Palamara. Beyond providing updated medical records and pointing to the objective evidence, Attorney Palamara also pointed to all the old reviews that Lincoln had conducted that supported this claim and the support from the treating providers. We also pointed out that Social Security still finds her to be disabled. Beyond this, Attorney Palamara was also very critical of how Lincoln handled this claim. It essentially lured this claimant to sleep and pulled the cord on the claim when she least expected it. It essentially ordered no updated records and then said she was not disabled as there was no proof. Well proof would have been provided if it was merely requested. In this case, Lincoln failed to request or order updated medical records. Lincoln failed to review the Social Security Disability Claim File. It even failed to distinguish the past reports it commissioned that were supportive of Ms. Falk’s claim. Everything pointed to the fact that Lincoln acted arbitrarily and capriciously here.
Thankfully, a few weeks after our appeal was filed, Lincoln informed us that her claim was being reinstated. Though our client is thankful, it was really tough for her to be without benefits for those few months. However, this case is pivotal if you are on claim and receiving disability benefits. Claimants must also remember that they have a duty to prove their claim. It is their duty to prove to the insurance company that they are disabled. Furthermore, claimants cannot expect the insurance company to prove it to themselves that the person they are paying is disabled. It is not even logical to expect them to prove to themselves that they should be paying someone. It is always important to continually prove your claim. If you don’t, expect your claim to be denied. Though we will gladly get you back on claim, you may go a few months without benefits.
If you have had a similar situation and Lincoln (or any disability insurance company) has denied your claim or if you are worried about being denied, please do not hesitate to contact Attorney Alexander Palamara at Dell & Schaefer for a free consultation.