Failure to treat your medical condition can lead to termination of long term disability benefits

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.

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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.

Dell & Schaefer Client Reviews   *****

Thomas S. DVM

When I first thought about a disability claim and what was required to qualify, I met with Greg Dell and he clearly spelled it all out for me. He quickly advised me that with my problems I was definitely deserving of benefits. I was given a choice between an hourly or percentage compensation rate. I choose the percentage rate as I wanted Greg to be a partner in my claim and handle all the complexities associated with getting paid and the continued documentation required.

I have had my share of experiences with lawyers and I have to say Greg Dell was the most professional as well as honest and caring one I have ever met. He makes no promises but points out all the facts in your case and what he feels you need to be successful. The e-mails sent are always answered promptly. I have to mention that his staff specifically Vanessa is always available and helpful. I believe it is possible to do the whole process yourself, but I WOULD NOT RECOMMEND IT. It is my personal opinion that the insurance company does not want to pay you no matter what and a good attorney is essential to navigate all the road blocks put in front of you. Thank you Greg for guiding me and helping me financially protect my family.

Gregory Dell’s reply:
Your kind words mean a lot to Vanessa and I. Thank you for the opportunity to work for you and I will continue to do everything I can to make sure your disability benefits continue to be paid each and every month.

***** 5 stars based on 202 reviews

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