Our client, who previously worked as a Registered Nurse for Adventist HealthCare since 1996, came to us after being denied continued ERISA long term disability (“LTD”) benefits by Hartford Life and Accident Insurance Co. Prior to being denied, our client had previously received benefits from January 27, 2010 through October 31, 2014. By way of a denial letter dated October 23, 2014, Hartford informed our client that benefits would terminate because it felt that she no longer satisfied the definition of disability in the policy which required her to be “prevented from performing one or more of the Essential Duties of Any Occupation.”
Under most LTD policies, this “Any Occupation” definition of disability typically becomes effective after benefits have been paid for 24 months. Prior to the “Any Occupation” definition, most policies require that the person be “prevented from performing one or more of the essential duties of Your Occupation.” Thus, it becomes more difficult to qualify for LTD benefits after the new definition of disability kicks in and this is the time when most people on claim get denied.
Our client was fortunate enough to receive benefits beyond the change in definition of disability. Our client’s fortune, however, changed nearly 3 years after the change in definition. In the aforementioned denial letter of October 23, 2014, Hartford found that she no longer satisfied the “Any Occupation” definition of disability based on covert surveillance, an in person interview they had conducted with our client, a review by Hartford’s Medical Case Manager and a report of an Independent Medical Evaluation.
Finding Dell & Schaefer
After receiving the notification of denial from Hartford, the denied Registered Nurse found our law firm and spoke with Attorney Alexander Palamara. Within days of contacting our firm, a letter of representation was sent to Hartford, the claim file was ordered and updated medical records were being requested so that a timely administrative appeal could be filed to challenge Hartford’s decision.
After reviewing all of the documentation, we were able to see that our client suffered from Complex Regional Pain Syndrome/Reflux Sympathetic Dystrophy of the Right Lower Extremity, Right Posterior Nerve Injury, Neuropathic Right Foot Pain, Neuralgia of the Nerves of the Right Foot and Ankle, Right Midfoot Osteoarthrosis, Right Ankle Osteophytes, Lumbar Spine Pain, Lumbago, Thoracic Spine Spondylosis, Degenerative Changes of the Thoracic Spine, Obesity, Type 2 Diabetes Mellitus, Asthma, Reactive Airways Disease, Aspiration Pneumonitis, Acute Pharyngitis, Connective Tissue Disorder, Right Pole Renal Calculus, Essential Hypertension, Mixed Hyperlipidemia, Irritable Bowel Syndrome, Gastroesophageal Reflux Disease (GERD),Tachycardia, Recurrent Cellulitis, Polycystic Ovaries, Saeture-Chotzen Syndrome and Recurrent Anxiety and Depression. The medical records made it crystal clear that Hartford’s decision was blatantly wrong and that our now client should still be receiving LTD benefits from the Hartford. Furthermore, a review of Hartford’s claim file showed that the documentation it relied upon to deny the claim was unreliable at best.
Administrative Appeal Filed
A timely administrative appeal was filed that challenged Hartford’s decision to deny our now client’s claim for continued LTD benefits. The appeal noted that Hartford’s Independent Medical Examination’s review was not based on medical records or an examination of our client, but rather it was based on the IME examiner’s review of covert surveillance that he observed. Due to this covert surveillance, the IME examiner found that our client had the ability to work 40 hours per week if she “is able to sit and change positions frequently.” This doctor ignored the findings of our client’s treating physicians and ignored the objective documentation. Furthermore, the IME examiner ignored the fact that the covert surveillance video was stale due to the fact that it was shot in August and September of 2013, one year before the IME examiner performed the review and before our client had 2 more major surgeries.
Beyond criticizing Hartford’s reviews, the administrative appeal summarized the objective medical evidence which proved that our client was still “prevented from performing one or more of the Essential Duties of Any Occupation.” Two weeks and two days after we sent the appeal to Hartford, Hartford sent us a letter agreeing that its denial was incorrect and informed us that her benefits were to be immediately reinstated with all past benefits owed to be sent at once.
Although our client faced months without her LTD benefits from Hartford, she is happy that Hartford made the correct decision and reinstated her claim. Our client knows that Dell & Schaefer will continue to do whatever it takes to keep her on claim until her policy expires.
If you have been denied disability benefits by Hartford or any other disability insurance provider, please do not hesitate to contact the Attorneys at Dell & Schafer for a free consultation.
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