Our client, Mr. K, formerly worked as an Account Representative for an international brokerage firm. In May 2017 a number of medical issues, including the debilitating effects of chronic congestive heart failure, arteriosclerotic heart disease of native coronary artery, chest pain forced Mr. K to stop working and submit his claim for disability benefits first under his employer’s short-term disability (STD) policy and then continuing under its long-term disability (LTD) policy. Both benefits were funded and administered by Hartford. Under his employer’s disability policy Mr. K would be considered totally disabled if he was unable to perform one or more of the essential duties of his own regular occupation. Essential duties included, among other things, those job tasks that were substantial, fundamental or inherent to the occupation, and could not be reasonably omitted or changed.
After submitting his claim, Hartford denied LTD benefits on the basis that he allegedly did not meet the policy definition of disability. Specifically, Hartford stated that that “the combined information in the file does not show that he is unable to perform the essential duties of his occupation on a full time basis as of [September 2017].” After receiving the denial, Mr. K contacted Dell & Schaefer and discussed his case with Attorney Jay Symonds. Attorney Symonds identified several significant issues in Hartford’s denial letter and in the evidence it relied on and agreed to prepare and submit Mr. K’s ERISA appeal with the assistance of his appeal team.
The LTD appeal addressed all of Hartford’s short-comings and reasons for denial, with a special focus on the medical records on and around the date of Hartford’s denial and significant inconsistencies with its medical reviewer’s findings. Specifically, Hartford’s LTD denial rested largely, if not exclusively, on an in-house medical review completed by an RN who was clearly not qualified to offer a medical opinion as to Mr. K’s complex cardiac medical condition. Further, Hartford’s nurse based her opinion to deny further benefits on a faulty, narrow reading of a single office note from one treatment provider, which ignored consideration of Mr. K’s complete medical picture and the co-morbid nature of his functional restrictions and limitations leading up to and after the date Hartford denied benefits. And finally, the appeal pointed out that neither Hartford nor its nurse reviewer made any attempt to determine whether Mr. K could perform his actual regular occupation.
A review of Mr. K’s duties and responsibilities with his employer clearly established that his regular occupation was quite complex, detail oriented and, at times, physically demanding. Yet, the denial letter never mentions the requirements of Mr. K’s regular occupation nor does it provide any analysis of how his physical and cognitive restrictions and limitations impact his ability to perform his job.
Less than two months later, and after reviewing the appeal and hundreds of pages of exhibits and medical records as well as the expert reports, Hartford overturned its decision to terminate benefits, paid full LTD back benefits and reinstated Mr. K’s LTD claim. Attorney Symonds continues to represent our client to best ensure that Hartford will not terminate his benefits again. Feel free to call our disability attorneys for a free consultation on this or any matter relevant to your disability claim.