Hartford overturned previous denial of long term disability benefits for New York Consultant

Our client, Mr. M, formerly worked as a trade consultant for an international accounting firm. In May 2017 a large lumbar disc herniation forced Mr. M to stop working and submit his claim for disability benefits first under his employer’s STD policy, which paid full benefits, then under its Long-Term Disability (“LTD”) Policy which was administered and funded by Hartford. Under the employer’s disability policy Mr. M would be considered totally disabled if he was prevented from performing one or more of the essential duties of his occupation unless his injury or sickness was subject to the policy’s pre-existing condition limitation. Under that provision, Hartford would not pay a benefit for a disability that “results from, or is caused or contributed to by… any manifestations, symptoms, findings, or aggravations related to or resulting from” his disabling condition “for which [he] received medical care” during the 180 consecutive day period ending the day before his effective date of coverage.

Hartford denied benefits in January 2018 on the basis that Mr. M allegedly was not eligible for benefits under the Policy. Specifically, Hartford “determined that [his] condition was Pre-Existing and is excluded by [the] Policy.” After receiving the denial, Mr. M 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. M’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 Mr. M’s disabling condition versus the pre-existing condition referenced by Hartford. More specifically, Hartford’s denial letter incorrectly stated that Mr. M was claiming benefits under the Policy due to diagnosis of low back pain and orthopedic aftercare following a Rhizotomy and anterior spinal fusion with a disability date in May 2017. While this may have been true of his claim under the STD policy, which does not have a pre-existing condition limitation, Mr. M’s LTD claim, which did not begin until November 2017, was based on restrictions and limitations associated with rhBMP-2 osteolysis, which is an extremely rare complication he suffered following the fusion surgery and which was not diagnosed until July 2017. In fact, Mr. M made this point very clear to his Hartford claims examiner during a telephone call in November 2017.

The appeal made clear that courts across the country agree that where a Policy excludes coverage for disabilities caused by pre-existing conditions, the carrier may not attempt to apply its Policy as if it excludes coverage for disabilities caused by complications from surgery for pre-existing conditions. Courts recognize that surgery is not, itself, a pre-existing condition, but at most a necessary consequence of a pre-existing condition. Thus, the question is where to draw the line on chain of causation. In Mr. M’s case the chain of causation contained five very attenuated stages, including a decision by Mr. M’s health insurer to reject an initially recommended course of treatment. Hartford’s acceptance of that extremely attenuated causal link effectively rendered meaningless the notion of the pre-existing condition clause by distending the scope of the exclusion. Courts have rejected such an attenuated and long chain of causal links, with unanticipated intervening causes, and instead have held that the disabling condition must be substantially or directly attributable to the pre-existing condition. Courts have also made the distinction that well-known complications from a disease may trigger the pre-existing condition exclusion but, as here, rare, unrelated and unanticipated complications from treatment or surgery would not.

Several months later, and after reviewing the appeal and hundreds of pages of exhibits and medical records, Hartford overturned its denial and referred the claim back to the claims examiner for a disability determination. Feel free to call our disability attorneys for a free consultation on this or any matter relevant to your disability claim.

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We represent Hartford clients nationwide and we encourage you to contact us for a FREE immediate phone consultation with one of our experienced disability insurance attorneys.

Can you help with a Hartford disability insurance policy?

Our disability insurance lawyers help policy holders seeking short or long term disability insurance benefits from Hartford. We have helped thousands of disability insurance claimants nationwide with monthly disability benefits. With more than 40 years of disability insurance experience we have helped individuals in almost every occupation and we are familiar with the disability income policies offered by Hartford.

How do you help Hartford claimants?

Our lawyers help individuals that have either purchased a Hartford long term disability insurance policy from an insurance company or obtained short or long term disability insurance coverage as a benefit from their employer.

Our experienced lawyers can assist with Hartford:

  • ERISA and Non-ERISA Appeals of Disability Benefit Denials
  • ERISA and Non-ERISA Disability Benefit Lawsuits
  • Applying For Short or Long Term Disability Benefits
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  • Disability Insurance Lump-Sum Buyout or Settlement Negotiations

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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.

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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.

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David F. (Hawaii)

My experience with Dell & Schaefer was beyond my expectations and during a very stressful time. Stephen F. Jessup was eager to help us when we first contact the office about 5 years ago. He was stellar with this follow up, extremely knowledgeable in the Cigna arena, and had some great out of the box ideas. What I appreciated the most about Stephan and Dell & Schaefer was how they stuck with us the entire time we were fighting the Cigna machine. There was times I was ready to give up but Stephan encouraged us to keep going.

We ended up settling a few days ago and it was well beyond our wildest dreams! To top it off, we were about 4,000 miles away from Stephen as we lived in Hawaii when we started working with Stephen and even though our time zone was 6 hours a part he was able to stay connected and represent us from afar.

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