Dell & Schaefer Successfully Appeals Denial Of Benefits To Claimant With Trigeminal Neuralgia
Author: Attorney Victor Peña
Ms. R contacted our firm after her claim for Long Term Disability (“LTD”) benefits was denied by Principal Life Insurance Company.
Before becoming disabled, Ms. R worked as a Litigation Support Assistant for a large, busy law firm. Ms. R had been experiencing head pain for several years with the symptoms first appearing in August 2012 and gradually worsening over time. In July 2015 her symptoms became so severe that her doctor advised restricted work activity. As of July 2015 Ms. R was experiencing severe head pain that was causing cognitive impairments and limiting her concentration. Eventually, the pain and resulting impairments became so severe that Ms. R was forced to stop working in September of 2015.
Following her leave from work, Ms. R filed a claim for disability benefits under her employer sponsored disability plan. Principal Life Insurance Company, the claims administrator, reviewed Ms. R’s claim for benefits and after months of reviewing Ms. R’s medical history, medical records, and reaching out to Ms. R’s treating physicians Principal denied the claim concluding there were no restrictions of work ability supported.
Given her debilitating condition, Ms. R was in no position to handle her appeal alone so with help from a friend she reached out to our firm for a free consultation. Ms. R spoke with Attorney Victor Peña who agreed to take on her case.
After reviewing the denial letter it became apparent that Principal had committed predictable errors. It also appeared that Ms. R’s doctors had been less than helpful. While her doctors were supportive and advised Ms. R to stop working the same doctors were not adequately documenting the medical records or properly responding to Principal’s requests. As a result, Ms. R’s claim had been denied.
Mr. Peña immediately began working on Ms. R’s appeal. Mr. Peña and his team gathered all medical records and reviewed Principal’s claim file for inconsistencies. After reviewing Principal’s claim file along with the denial letter it also became apparent that those who made the decision to deny Ms. R’s LTD claim did not fully understand the nature of Ms. R’s condition. Ms. Russo has been suffering with what is considered to be one of the most painful afflictions known to the medical practice. According to the Facial Pain Association Trigeminal Neuralgia (TN) is a disorder of the fifth cranial (trigeminal) nerve. The typical or “classic” form of the disorder (called TN1) causes extreme, sporadic, sudden burning or shock-like facial pain in the areas of the face where the branches of the nerve are distributed—lips, eyes, nose, scalp, forehead, upper jaw, and lower jaw. The “atypical” form of the disorder (called TN2), is characterized by constant aching, burning, stabbing pain of somewhat lower intensity than TN1. Both forms may occur in the same person, sometimes at the same time.
According to TNA Facial Pain Association:
“The trigeminal nerve is one of 12 pairs of nerves that are attached to the brain. The nerve has three branches that conduct sensations from the upper, middle, and lower portions of the face, as well as the oral cavity, to the brain. More than one nerve branch can be affected by the disorder. Rarely, both sides of the face may be affected at different times in an individual, or even more rarely at the same time (called bilateral TN).
The intense flashes of pain associated with TN can be triggered by vibration or contact with the cheek (such as when shaving, washing the face, or applying makeup), brushing teeth, eating, drinking, talking, or being exposed to the wind. Often, people with TN avoid social and daily activities such as eating and talking out of fear of an attack. Many people have been known to lose their jobs due to the debilitating pain.”
Ms. R suffers from a severe case of TN with attacks worsening over time. The symptoms eventually became so severe that she could no longer function in the workplace.
Unfortunately, like many chronic pain conditions which are difficult to prove, Principal did not fairly consider the effects this pain would have on Ms. R’s ability to work and did not believe the medical records adequately supported work restrictions.
Mr. Peña focused the appeal on educating Principal’s claim analysts on Ms. R’s condition and on gathering the right evidence to construct an effective appeal. Mr. Peña worked with his appeal specialist in drafting physician questionnaires that were specific to Ms. R’s condition. The responses from Ms. R’s treating physicians were overwhelmingly positive as they were now being asked the right questions.
As is the case in many disability claims, insurance companies will send general questionnaires to treating physicians that do not elicit the right responses to adequately review a disability claim. This is often a problem when a claim is based on a rare condition such as Trigeminal Neuralgia.
After submitting the appeal, Mr. Peña worked closely with the claims analyst handling Ms. R’s appeal. During the appeal review, Principal requested that Ms. R undergo an independent medical evaluation. Unlike many disability policies, the policy at issue did not contain a provision requiring Ms. R to undergo such an evaluation during the appeal review. Given the nature of Ms. R’s condition, Attorney Peña decided an IME would not be helpful to Ms. R’s claim and could only serve to allow Principal to build evidence against Ms. R’s claim.
After a lengthy review, Principal made a decision on Ms. R’s appeal and overturned its initial decision to deny the claim. Principal paid all back benefits owed and reinstated Ms. R’s claim going forward.
Ms. R continues to be disabled and remains on claim. Attorneys Dell & Schaefer continues managing her claim with Principal.