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Dell & Schaefer Successfully Appeals Denial of Benefits to IT Support Specialist

Attorney Victor PeñaAuthor: Attorney Victor Peña

Pre-disability and initial disability claim

Before contacting our firm, Ms. Z had been on claim for long term disability (“LTD”) benefits for 3 years. Ms. Z was an IT Support Specialist for the county library system where she lived when she was forced to go on disability due to severe right hip dysplasia, osteoarthritis of the right hip, chronic pain and a number of other medical issues that collectively made it impossible for Ms. Z to continue working. Fortunately, Ms. Z was covered by her employer’s LTD policy, which was administered by Lincoln National Life Insurance Company (“Lincoln”). Given the nature of her condition and the unquestionable limitations on Ms. Z’s ability to work, Lincoln approved Ms. Z’s disability claim.

According to the LTD policy, to qualify for disability benefits during the first 36-months, Ms. Z would have to be unable to perform each of the main duties of her Own Occupation. Following the 36-month “own occupation” period, the medical evidence would have to support that Ms. Z is unable to perform each of the main duties of any gainful occupation which her training, education or experience will reasonably allow.

The 36-month own occupation ended on 5/20/2014 and in January 2015 Ms. Z received a letter from Lincoln stating that Ms. Z’s benefits had been terminated as she no longer met the definition of disability. Lincoln had made this decision based solely on an internal file review which concluded that Ms. Z has “sedentary work capacity and therefore is able to perform each of the main duties of a Nut Sorter, Addresser, and Typist”—occupations which, according to Lincoln would provide Ms. Z with an earnings potential of over $43,000 per year.

Lincoln’s reviews were done although Lincoln did not have any current medical information regarding Ms. Z’s current work capacity. Additionally, despite a lack of current information and the policy at issue giving Lincoln the right to have Ms. Z evaluated by a physician of its choice, Lincoln failed to exercise that right. In other words, Lincoln declined to have Ms. Z seen by a doctor before terminating her claim and instead relied solely on a review of outdated medical information in deciding to terminate Ms. Z’s continued claim for benefits.

Ms. Z contacts Attorneys Dell & Schaefer

After receiving her denial letter, Ms. Z contacted Attorneys Dell & Schaefer and spoke with Attorney Victor Peña. After reviewing the denial letter and discussing the claim with Ms. Z, Mr. Peña agreed to assist Ms. Z with her appeal.

To provide Lincoln with updated and objective information regarding Ms. Z’s work capacity, Ms. Z underwent a Functional Capacity Evaluation (“FCE”) on October 23, 2014. The FCE revealed that Ms. Z has severe limitations which would make it impossible to work with reasonable continuity throughout an 8-hour work day. The appeal included a copy of the FCE report, updated medical records and a detailed summary of the relevant medical records as well as a methodical analysis of the flaws in Lincoln’s review.

Lincoln’s review of the First Appeal

During its appeal review, Lincoln again declined to have Ms. Z seen by a physician and instead had the file reviewed by a doctor certified in Physical Medicine and Rehabilitation and Pain Medicine. Lincoln’s doctor, Dr. Philip Marian, acknowledged that Ms. Z has well-documented underlying degenerative right hip impairment, as well as well-documented right hip degenerative progressive osteoarthritis, associated pain and stiffness and difficulty with long-term sitting, standing and walking. However, Dr. Marian dismissed the well documented findings relying on a perceived notion that Ms. Z is “otherwise independent with activities of daily living including dressing, hygiene and grooming” as well as “functionally capable of driving a motor vehicle.” Based on this, Dr. Marian determined that Ms. Z is capable of sitting for seven hours out of an 8-hour day, lifting not more than 10 lbs. occasionally and possible frequent lifting of small objects.

Dr. Marian, without even seeing Ms. Z, dismissed the restrictions given by Ms. Z’s treating physician, and dismissed the recent functional capacity evaluation performed on 10/23/2014.
Needless to say, Lincoln relied on Dr. Marian’s flawed report and denied Ms. Z’s first appeal.

Lincoln’s review of the Second Appeal

Unlike many other disability carriers, Lincoln often has a second required level of appeal that must be exhausted before a lawsuit can be filed in federal court. Attorney Peña took this opportunity to tear apart Lincoln’s first appeal review and address the unreasonable decision.

Mr. Peña pointed out that it was unreasonable for Lincoln to dismiss the supporting medical documentation based on Ms. Z’s ability to perform certain activities of daily living. It was noted that Ms. Z had made Lincoln aware that she does not perform all ADLs on her own and she has things like groceries delivered to her home. She is able to bathe alone since bars are installed in her shower and she moves things that she needs by the tub. Moreover, she is able to get through the day on heavy pain medications. Nevertheless, Ms. Z’s ability to take care of herself does not equate with full time work capacity and it is not reasonable for Lincoln to simply dismiss the voluminous support of Ms. Z’s disability simply because she can perform certain activities of daily living.

Additionally, Mr. Peña addressed the unreasonableness in Lincoln’s decision to dismiss the results of the FCE. He thoroughly explained the results of the FCE and detailed the arbitrary and capricious nature of Lincoln’s decision. More importantly, Mr. Peña attacked Lincoln for ignoring credible and objective evidence of Ms. Z’s disability and for declining to have Ms. Z evaluated in person by a doctor of Lincoln’s choice.

Lincoln overturns its adverse decision

Exercising its rights under the LTD policy, Lincoln requested that Ms. Z undergo an Independent Medical Evaluation (“IME”) by a doctor of its choice. While Ms. Z could not refuse a reasonable request, Attorney Peña demanded that Lincoln find a doctor who would allow a videographer to record the entire evaluation. Fortunately, the IME physician performed the IME in the presence of a videographer and less than two weeks later a letter was sent to Attorney Peña with Lincoln’s decision on appeal. The letter, dated August 18, 2015, advised that Ms. Z’s claim had been reinstated and all back benefits owed would be issued under separate cover.

Like many other claimant’s, Ms. Z would have found it incredibly difficult to fight Lincoln on her own. The demands made by the disability carrier to continue a disability claim can be both physically and mentally burdensome. It is often said that handling a disability claim is much like working a full time job—which, ironically, is impossible for many disabled persons to do as he/she would presumably be working if he/she had the ability to do so.

Fortunately, Ms. Z will not be alone at any point throughout the remainder of her claim.

Attorneys Dell & Schaefer will continue managing Ms. Z’s claim with Lincoln and will fight to ensure Ms. Z’s disability checks continue as long as Ms. Z remains disabled.



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