GE Benefit Denial Overturned For Plaintiff with Permanent Loss of Function of His Foot

In Stockman v. GE Life, Disability and Medical Plan et al., the plaintiff severely injured his foot and totally lost the function of it for 12 months. He then applied for benefits under the GE Life policy claiming he suffered a “total and permanent” loss of the use of his foot. MetLife, Plan Administrator for GE, denied his claim on the grounds that the loss was not total and permanent. Both the Ohio district court and appellate courts disagreed with MetLife. The appellate court concluded: “If Stockman’s injury, which has resulted in the ‘permanent’ loss of the use of his foot in the way that a foot should be used does not qualify him to receive benefits, we are unsure of a situation, absent actual severance, where a claimant would qualify.”

Brief History of the Case

In 2009, Steven Stockman severely injured his foot when he fell off a second story ladder. Subsequently, he underwent seven separate surgical procedures and contracted several infections that required extensive treatment. After 12 months of total loss of the use of his foot, he applied for benefits under the policy that covered accidental dismemberment with the definition of dismemberment being the “permanent and total loss of function of the hand or foot as a result of an accident after the loss has continued for at least 12 consecutive months.” The plan denied him benefits and after he exhausted his administrative appeals, he filed a lawsuit under the provisions of ERISA.

MetLife did not dispute the fact that Stockman had lost the function of his foot for 12 consecutive months as required by the plan, but argued the loss of function was not total and permanent since, after the expiration of the 12 months, he was able to walk with a cane. In court, the resolution of the case depended on the definition of the word “permanent”.

MetLife argued that “permanent” means there will never be any improvement, and since the condition of Stockman’s foot had improved after the 12 month eligibility period to the extent that he could occasionally walk without a cane, his injury was not permanent. Stockman argued that the dictionary definition of permanent should be used which describes something as permanent when it is “enduring without fundamental or marked change.”

The Court’s Final Decision

The district court agreed with Stockman and stated that the “mere fact that his foot is still attached to his body” is not enough to decide the foot is functional. The appellate court agreed with the district court and concluded that if MetLife’s definition of permanent were followed, it would be superfluous. No claimant whose foot had not been severed would ever be able to collect benefits. That court agreed with the district court’s conclusion that Stockman was entitled to benefits since “the plan allowed for benefits when a person has suffered an injury that, for all intents and purposes, has resulted in the loss of the use of the foot to the point where it no longer serves the purpose it was intended to serve and will never be able to serve that purpose.” Since Stockman’s medical records supported that definition, the district court determined he was entitled to benefits and the Court of Appeals for the Sixth Circuit agreed.

This case was not handled by our office, but it may provide claimants guidance in their pursuit of compensation under the accidental dismemberment clause of an insurance policy. If you need assistance with a similar matter please contact any of our lawyers for a free consultation.

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Jim F.

My employer offered both Short Term Disability and Long Term Disability insurance as optional benefits among others. The premiums were significant, but since they could be payroll deducted I felt they could be reasonably managed and the security of continued income in the event of a medical disability was well worth the investment. As with the purchase of a first aid kit, most would prefer never having to use it.

I have been very fortunate to have had few illnesses or injuries throughout my life and more specifically my 45 year career as a healthcare professional. It wasn’t until early in 2012 that I was diagnosed with a chronic, progressive disease of the eye. Symptoms were minimal at that time, though regular visits to a retinal specialist, including regular therapy by ocular injection, were necessary to slow its progression, the symptoms did not appreciably interfere with my work. In spite of my treatments the condition continued to progress. In early 2014 the symptoms began to interfere dramatically with my day to day duties. My job required significant computer use and the reading of copious amounts of medical documentation. It became evident to me that I could no longer meet the expectation of my management and clinical position without working frighteningly long hours and enduring the relentless eye strain and other symptoms related to the illness.

Though I had always planned for eventual retirement from my full-time position, like most professionals I had hoped to be able to continue to practice my profession on a part-time basis throughout my retirement as long as I remained competent and able. That was not to be. Thankfully, I had the foresight to elect the disability benefit options offered by my company and have the premiums payroll deducted for many years. I notified my supervisor and HR representative that I had to stop working due to my condition and proceed with the disability application process.

All went very well and after using up my accrued vacation and sick time, my short-term disability benefits commenced. Since my condition is progressive and incurable I felt secure in knowing that once my short-term benefits were exhausted my benefits would continue under the long-term policy. However, much to my surprise, after receiving about a month of benefits I received notification from the insurance company that a decision had been made to terminate my benefits due to lack of objective medical evidence to support my claim, though significant documentation had been provided by my retinal specialist.

I was bewildered and unsure of how to proceed with an appeal of that decision. Since I had 180 days to do so, I decided to research the matter thoroughly. In spite of my being a veteran healthcare professional everything I had been reading on the subject cautioned about attempting to proceed with an appeal on my own. Legal representation was highly recommended.

I then began a review of local attorneys, hoping to find one that provided enough documentation on their website that indicated experience with non-social security disability related cases. I was also interested in seeing evidence of some experience with disability cases related to diseases of the eye and resultant vision impairment. I was unsuccessful.

So I expanded my search to include national law firms. It was then that I discovered Dell & Schaefer. After thoroughly reviewing their website, watching many of the video discussions, noting experience with vision related cases, particular documentation related to the insurance company that handled and then eventually denied my benefits, and reading a significant number of testimonials, I decided to request a free consultation as advertised. It was one of the best decisions I have ever made.

After that consultation, I was very confident that I was in very skilled hands which alone reduced my anxiety level immensely. Attorney Alexander Palamara and his Legal Assistant, Kathleen Bordes, immediately began managing my case, their professional expertise clearly evident.

They worked closely with my retinal specialist, my optometrist and the insurance company in compiling the medical documentation necessary for a successful appeal in an amazingly short period of time, keeping me fully informed all along the way. Shortly after being notified by the insurance company that my benefits would be reinstated and paid through the full term of my short-term policy I received a lump-sum payment.

Once the short-term disability appeal was successfully completed, Alex and Kathy immediately addressed the long-term policy benefits. Again in a remarkably short period of time I was granted those benefits, receiving a lump-sum payment for benefits to date and will receive a payment monthly going forward per the terms of my LTD policy.

I am extremely pleased with how my case was handled and the very favorable outcome. Alex and Kathy were a delight to work with and extremely professional in every way. Incidentally, the fee I paid to Dell and Schaefer for their incredible representation was very reasonable and very well earned.

I highly recommend the services of Dell & Schaefer to anyone who may find themselves in a similar disability-related situation.

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