Northern District of Illinois determines the exception to The Standard’s “limited conditions” provision does not apply when plaintiff failed to provide current positive MRI evidence of a herniated disc

It is very common for group disability policies to contain provisions limiting LTD benefits to 12 or 24 months for conditions involving the cervical or lumbar spine as well as soft tissue injuries. It is important to be familiar with your policy language and its limitations prior to filing a claim for benefits, especially if your policy contains a limitation for certain medical conditions. It is often times possible to get around these limitations if you are able to provide objective medical support of a condition falling under one of the exceptions provided in the plan. If you are suffering from one of the limited conditions in your plan, it is extremely important to address this issue with your treating physicians in order to determine whether additional testing may provide evidence of one or more of the possible exceptions to this limitation.

An example of this exact issue was addressed in an April of 2014 decision, out of the Northern District of Illinois, Zaccone v. Standard Life Insurance Company. The LTD Plan at issue contained the following limitations:

Payment of LTD Benefits is limited to 12 months during your entire lifetime for a Disability caused or contributed to by any one or more of the following, or medical or surgical treatment of one of the following:

3. Other Limited Conditions.

Other Limited Conditions means… chronic pain conditions… arthritis, diseases or disorders of the cervical thoracic, or lumbosacral back and its surrounding soft tissue…

However, Other Limited Conditions does not include… herniated discs with neurological abnormalities that are documented by electromyogram and computerized tomography or magnetic resonance imaging, scoliosis, radiculopathies that are documented by electromyogram, spondylolisthesis, grade II or higher, myelopathies and myelitis, traumatic spinal cord necrosis, osteoporosis, discitis, Paget’s disease.

Plaintiff Fails to Provide Recent Objective Proof of Neurological Condition

In an effort to get around the “Other Limited Condition” provision in his plan, Zaccone provided the Standard with an MRI from 1992 which revealed a herniated disc. According to Zaccone, this MRI was sufficient evidence of a “neurological abnormality that is documented by MRI.” However, according to the Standard and the Court agreed, the 1992 MRI was insufficient objective proof of his lumbar condition. The Court reasoned that Zaccone underwent a lumbar laminectomy and discectomy in 1992, after the MRI was done, which were both successful as described by his neurosurgeon. Since 1992, there had been no additional evidence on MRI or otherwise to indicate the plaintiff had a herniated disc or any tests such as a positive EMG indicating radiculopathy. The Plaintiff argued that the plan was ambiguous as it does not specify the time frame in which the evidence must date back to. The Court disagreed, holding that the plaintiff is disabled due to degenerative disc disease, but without more recent objective proof, his claim is limited to 12 months.

The Zaccone case is a prime example of why it is pertinent to be familiar with the exclusions and limitations in your plan, to ensure that your treating physicians are aware of these as well and to request that your physicians order all possible objective tests including MRI’s, CT scans, EMG’s in order to provide recent objective evidence of your disability due to a cervical or lumbar condition.

The law firm of Dell & Schaefer did not handle the Zaccone case, but our firm represents many clients with disabilities similar to Zaccone, who are faced with the challenge of refuting the limitations contained in their LTD policies. When representing our clients, it is our goal to help ensure that he or she is receiving the proper medical care, the proper tests have been ordered by their doctors and most important, that the client and his or her physicians have an understanding of the limitations contained in their policy.

DISABILITY INSURANCE COMPANY INFORMATION
Videos, Questions, Resolved Cases, Lawsuit Summaries & Company Reviews

disability insurance companies complaints

View videos, articles, resolved cases and claimant reviews about your specific disability insurance company.

Leave a comment or ask us a question

There are 2 comments

  • Rich,

    Unfortunately, depending on applicable plan language that may preclude payment of benefits beyond a certain period a person may not be entitle to additional benefits.

    Stephen JessupDec 19, 2014  #2

  • So those of us who have had prior surgeries – repairing fractures, herniations – which have not resolved pain and have led to diagnosis of failed back syndrome are out of luck?

    RichDec 18, 2014  #1

FAQ

Do you work in my state?

Yes. We are a national disability insurance law firm that is available to represent you regardless of where you live in the United States. We have partner lawyers in every state and we have filed lawsuits in most federal courts nationwide. Our disability lawyers represent disability claimants at all stages of a claim for disability insurance benefits. There is nothing that our lawyers have not seen in the disability insurance world.

What are your fees?

Since we represent disability insurance claimants at different stages of a disability insurance claim we offer a variety of different fee options. We understand that claimants living on disability insurance benefits have a limited source of income; therefore we always try to work with the claimant to make our attorney fees as affordable as possible.

The three available fee options are a contingency fee agreement (no attorney fee or cost unless we make a recovery), hourly fee or fixed flat rate.

In every case we provide each client with a written fee agreement detailing the terms and conditions. We always offer a free initial phone consultation and we appreciate the opportunity to work with you in obtaining payment of your disability insurance benefits.

Do I have to come to your office to work with your law firm?

No. For purposes of efficiency and to reduce expenses for our clients we have found that 99% of our clients prefer to communicate via telephone, e-mail, fax, GoToMeeting.com sessions, or Skype. If you prefer an initial in-person meeting please let us know. A disability company will never require you to come to their office and similarly we are set up so that we handle your entire claim without the need for you to come to our office.

How can I contact you?

When you call us during normal business hours you will immediately speak with a disability attorney. We can be reached at 800-682-8331 or by email. Lawyer and staff must return all client calls same day. Client emails are usually replied to within the same business day and seem to be the preferred and most efficient method of communication for most clients.

Reviews

Bruce R. (Arizona)

Steve Dell has done an exceptional job with my disability application process. The firm is extremely well managed. They have acquired an incredible amount of experience over many years. I recommend them for disability insurance claims without reservation. 

Don (Florida)

I called this firm a few months ago completely disparaged due to a company cutting off disability benefits at a time that nearly caused me to lose everything.

Attorney Alex Palmera and Danielle worked hard to reach an amicable settlement and my case was settled a few months later. This is a good firm and the specific expertise in disability claims saved me countless hours of hassle at a time when an already fragile state existed.

Thank you Mr. Palamara and Danielle.

Sandra B. (Arkansas)

I have nothing but good things to say about how my buyout was handled with my disability claim. The level of professionalism was amazing. All of my questions and concerns were answered either by Danielle L. or Alex P. in such a timely manner and with such care I would recommend them in a heartbeat to anyone needing to approach their provider with buyout options.

They did a fantastic job communicating between the provider and me, always keeping my best interest at heart and always answering my many many questions. They really did take most of the stress out of this whole situation. I would give them a 10 out of 10 for every step of this crazy journey. Thank you so much for helping me through this.

Speak With An Attorney Now

Request a free legal consultation: Call 800-682-8331 or Email Us