Dell & Schaefer Administrative Appeal for Cafeteria Manager Forces Lincoln to Re-Approve Disability Claim
Author: Attorney Alex Palamara
On August 26, 1988, our now client was hired by the Worth County School District. She worked as the School Nutrition Manager, essentially a Cafeteria Manager, where she managed a staff of 8 and ordered, served, and prepped food for students. For over 27 years, our now client worked consistently at a job she clearly enjoyed that became her life. Unfortunately for her, at the age of 58, various medical conditions frustrated her ability to perform the duties of her own occupation. After suffering from Severe Degenerative Changes in her Lumbar Spine, Arthritis in both knees, Shoulder Pain, and Cardiac Issues, it was clear that continued employment was an impossibility. Luckily for her, the Worth County School District provided her with coverage under a long term disability insurance policy and thankfully it was with The Lincoln National Life Insurance Company.
After her claim was initially filed, Lincoln approved it and paid benefits from December 3, 2015 through December 3, 2017. Unfortunately for our now client, she was informed on July 31, 2017 that benefits would cease as of December 4, 2017, which coincidentally would be her 61st birthday.
In support of its decision to deny continued benefits, Lincoln first noted that the definition of disability under the Policy governing her claim changes after 24 months of benefits are paid. Therefore, as of December 4, 2017, in order to be considered disabled and in order to continue to receive continued benefits under the policy, at that time she would have to be “unable to perform each of the main duties of any gainful occupation.” Previously, she was only required to prove that she was “unable to perform each of the main duties of her own occupation.” Furthermore, Lincoln relied upon the fact that one of her treating physicians completed a form for Lincoln wherein he check-marked a box that indicated that while his patient was disabled from her own job, she was not disabled from any other work. Lincoln ran with this and apparently found some sedentary jobs it believed that she could perform. With all this, Lincoln denied her claim.
Claimant Files her Own Appeal
Knowing that there was no way that she could perform any occupation and knowing that Lincoln’s decision to deny her benefits was wrong, the former School Nutrition Manager attempted to file an appeal on her own to challenge Lincoln’s denial. While her appeal was a good attempt at getting herself back on claim as she did have her treating doctor fix the form that stated she could perform other work, unfortunately it was not enough and did not sway Lincoln to change its mind. By way of an October 31, 2017 denial letter, Lincoln upheld its previous decision to deny her claim. In support of this decision, Lincoln was now relying upon a review by a “health care consultant” who found insufficient clinical evidence of any functional impairment that would preclude her from any occupation. Knowing that decision was wrong and that she was disabled, she knew another appeal must be filed. At that time, she found our firm and Attorney Alexander Palamara who agreed to help her get back on claim.
Dell & Schaefer Gets Involved and Files An Appeal
After the initial phone call with our now client, it was clear that there was no way she could perform any occupation. The claim file was ordered as well as updated records. We also reached out to her treating physicians to get some clarification on their opinions on her claim. Lastly, we arrange for our client to undergo a Functional Capacity Evaluation (FCE) which would show her physical abilities and inabilities.
After all the documentation was gathered and reviewed, a timely appeal was filed to challenge Lincoln’s denials. The appeal focused on objective evidence such as MRI’s that showed clear diagnoses, support from her physicians that showed that they actually believed there was no way she could perform any occupation due to her restrictions and limitations and the medications she required, and the results of the FCE which confirmed she did not meet the criteria for even a sedentary occupation.
By way of a letter dated July 9, 2018, Lincoln informed us that as a result of the appeal we filed it decided to overturn its claim denial and reinstate benefits. A check for the benefits owed from December 4, 2017 to the present was promptly paid and our client will continue to enjoy LTD benefits until her policy expires at age 65 because she knows we will do whatever it takes to keep her on claim.
If you have had any issues with your claim for LTD benefits with Lincoln or any other disability insurance provider, please do not hesitate to contact Attorney Alexander Palamara at Dell & Schaefer. We always offer a free consultation and look forward to helping you.