Dell & Schaefer Wins Short Term Disability Appeal Against Lincoln

Prior to contacting our office to assist her in fighting Lincoln to secure her short term disability benefits, our client, a Financial Controller suffering from Multiple Sclerosis was denied  short term disability benefits twice by Lincoln. Following her initial denial she filed her own first appeal in hopes of having her benefits approved. Unfortunately, Lincoln notified her that her first appeal was also denied due to a lack of medical evidence to support her inability to work. Concerned with the fact that no money was coming in and her employer was threatening to terminate her employment she felt at a complete loss as to what to do to prove to Lincoln that she was not be able to work due to her condition. At that time she contacted our office and spoke with Attorney Stephen Jessup.

During their initial consultation Attorney Jessup reviewed the denial letters and the applicable short term disability policy. It was noticed immediately that Lincoln was utilizing different policy language in the denial letter than what was actually written in the policy. Specifically, Lincoln was quoting an “any occupation” standard of disability in their denial letters as opposed to the proper “own occupation” standard of disability. This alone called into question the thoroughness of the review conducted, but this blatant error would by no means be the only questionable action Lincoln undertook in reviewing our client’s claim.

Lincoln improperly evaluated our client’s occupational duties.

Lincoln policies contain a “national economy” standard as it relates to one’s “own occupation.” Meaning Lincoln does not look at how you perform your job for your employer or at your specific location, but rather how your job is performed in the national economy. In doing this Lincoln relies on vocational and governmental resources to determine the generic duties that one’s job entails. However, as was the case with our client, Lincoln only paid lip service to the actual job duties identified and instead focused solely on the physical requirements of the job as set forth by the Department of Labor. In our client’s case her occupation was performed at a Sedentary demand level, and it came as no surprise to Attorney Jessup when Lincoln advised our client in its initial denials that Lincoln determined there was no medical evidence to support her inability to perform at Sedentary demand level. How did Lincoln determine this? By tricking her doctor.

Lincoln’s claim form for the doctor to fill out purposely set our client up for failure.

In determining that our client was capable of Sedentary work Lincoln relied on our client’s own doctor’s opinion – or more accurately, how it was presented on Lincoln’s biased claim form. The form Lincoln sent to our client’s doctor for completion to determine physical ability only provided an option to check a box that indicated Sedentary, Light, Medium, Heavy or Very Heavy physical ability. There was no option to select below a Sedentary level, nor was their space designated for the doctor to write their opinion or elaborate on their selection. In turn, our client’s doctor selected the severest level of restriction – Sedentary.  That indication was all it took for Lincoln to deny the claim by asserting that our client’s doctor said she could work. As Attorney Jessup would argue in his appeal, that conclusion flew in the face of all the available medical evidence and opinions of our client’s doctor as set forth in the medical records.

The Appeal.

Unlike any other insurance company, Lincoln has a mandatory two levels of appeal before a lawsuit can be brought in federal court to secure benefits under ERISA. As such, this was our client’s last opportunity to provide information needed to support her inability to work. Due to the nature of our client’s medical condition Attorney Jessup knew from handling numerous disability claims for clients with Multiple Sclerosis that it would be important to verify physical as well as cognitive limitations our client was experiencing. Attorney Jessup knew that Lincoln would try to downplay and compartmentalize our client’s symptoms in an attempt to argue that our client’s complaints were all subjective in nature, and therefore unable to be verified outside of her own report.

To combat this, Attorney Jessup arranged for our client to undergo a functional capacity examination in order to verify physical restrictions and limitations as well as neuropsychological testing in order to document the cognitive limitations our client was working. By taking this approach Attorney Jessup knew he could prove our client did not have the ability to work at a “Sedentary” demand level as Lincoln argued in the denial letters, as well as prove our client would not be able to meet the cognitive demands of her occupation. Once the tests results were back Attorney Jessup then had a vocational analysis performed by an expert to serve as further evidence of our client’s inability to perform the material duties of her occupation.

Lincoln approves short term disability, but long term is still undecided.

Although Lincoln had 45 days under the law with which to render a decision on the appeal, within a month of filing the appeal Lincoln approved our client’s claim through the maximum short term disability benefit period. Although Lincoln insures our client’s long term disability policy the award of short term disability benefits did not mean our client’s long term disability claim has been approved. Lincoln’s long term disability department forwarded claim forms to be completed in order to determine our client’s right to long term disability benefits. Attorney Jessup continues to represent our client through this process.

Do you need help with Lincoln?

If your claim has been denied by Lincoln or you have questions regarding your claim please feel free to contact our office and speak to Attorney Jessup or one of our other disability attorneys to discuss your rights and assess how we may be able to assist you.

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