All disability policies require a long term disability claimant to receive appropriate care and treatment throughout the entire duration of a disability claim. Failure to do so can and will result in termination of disability benefits permanently. A Federal Judge in Florida recently ruled in favor of American International Life, Assurance Company of New York, in an ERISA Disability Lawsuit. Although our firm did not handle this case, this ruling teaches us that when a Long Term Disability Policy requires a claimant to be under the “regular care of a physician” and to be receiving the recommended treatment, should the claimant hesitate to receive such treatment or see his/her physician, the Insurance Company is justified in denying continued benefits.
The Underlying Facts of the LTD Claim
The plaintiff was employed as a Senior Litigation Specialist for AIG. As an employee of AIG, she was a participant and covered under a Long Term Disability Policy (LTD) which would provide her monthly benefits should she become unable to perform the material and substantial duties of her regular occupation. While at work on October 26, 2004, she injured her knee. She applied for and was approved for both Short Term and Long Term Disability Benefits. American International Life paid her LTD benefits until October 12, 2006. At that time, the insurance company refused continued benefits because it felt that the claimant “failed to meet the Plan language for being under the ‘regular care of a physician.'”
The claimant appealed the insurance company’s ruling, but her appeals were unsuccessful. After exhausting the administrative remedies, an ERISA lawsuit was filed in a Florida Federal Court.
The Court’s Analysis and Ruling
The American International Life Long Term Disability Plan for AIG employees states that benefits will terminate when the claimant is “no longer under the Regular Care of a Physician.” Additionally, benefits will terminate on “the date (the claimant) refuses to receive recommended treatment that is generally acknowledged by physicians to cure, correct or limit the disabling condition.”
The Court noted that in this case, the claimant’s own orthopedist recommended arthroscopic surgery. Likewise, the claimant’s second orthopedist fully agreed that arthroscopy was the proper treatment. The Insurance Company’s independent reviewers also indicated full agreement that arthroscopy was the proper procedure to cure or correct the claimant’s knee injury.
After each of her doctors recommended arthroscopic surgery, the claimant delayed having the surgery for 2 years and even failed to see her treating physician for over a year. During this delay, the insurance company denied her continued claim. The Court noted that the plaintiff failed to submit to the insurance company any medical evidence to challenge the opinions of any of the physicians. As such, the court ruled that the insurance company’s decision to deny continued disability benefits was correct and entered a final judgment in favor of the insurance company.
Although this case was not handled by Attorneys Dell & Schaefer, Chartered, we can learn from this claimant’s mistakes. It is very important to have a great awareness of the responsibilities one might have as a claimant under your long term disability policy. This situation could have been easily avoided should the claimant have known about the “Regular Care of a Physician” and “Recommended Treatment” Clauses. Additionally, this situation could have been averted had the claimant been represented by competent counsel. The disability attorneys at Attorneys Dell & Schaefer , Chartered, represent claimants nationwide and are available for a free consultation to discuss your disability claim options.