Hartford’s unreasonable denial of disability benefits to a hospital employee is reversed by Texas Court

Aside from the fact that many disability insurance companies already have a conflict of interest for being both the administrator of benefits and the entity that decides whether or not an employee qualifies for disability insurance, there are some cases in which it appears that insurance companies simply decide they don’t want to pay disability benefits.

Pamela Alexander began suffering with pain in 2002, when she worked as a transplant coordinator at a hospital. Having long-term disability insurance through her employer, Pamela applied and was denied in 2003, and two subsequent denials by Hartford Life occurred in March and September of 2004,  after administrative appeals.

In 2003, Alexander had a Functional Capability Examination (FCE), which stated that while she was technically ‘qualified’ to lift 17 pounds occasionally and 9 pounds frequently; lifting this amount more than 5 times a day would put her at medical risk. The examining doctor clearly stated in the FCE that Alexander should be lifting no more than 13 pounds occasionally and 7 pounds frequently. The FCE also stated that the ‘Return to Work Status’ was NO.

Hartford hired Dr. Elizabeth Roaf to conduct a paper review of Alexander’s medical records. It should be noted that Dr. Roaf never personally examined Alexander. However, Hartford’s final denial for benefits letter denying Alexander’s appeal stated that Dr. Roaf “noted the results of your June 3, 2003 Functional Capacity Evaluation, which indicated that you could function in a light duty capacity.”  Hartford misinterpreted the facts – as the FCE stated that Alexander “should not return to work at all”.

Therefore, the final denial for disability benefits makes no sense at all, especially since that letter stated that Alexander was ‘limited to 15 pounds pushing and pulling.’ Hartford’s occupational requirements for Alexander’s job stated she would be ‘lifting, carrying pushing, and pulling 20 lbs occasionally.’ In response to Hartford’s denial of Alexander’s disability benefits, Alexander filed a lawsuit in the United States District Court of the Northern District of Texas. The District court found in favor of Hartford, however, Alexander quickly appealed the courts decision.

Hartford’s Wrongful Denial Overturned on Appeal

The appeal court overturned the decision made by the district court, stating “that the insurer abused its discretion in denying the employee’s long-term disability claim because there was no rational connection between its conclusion that the employee was not disabled and the information on which it relied to support that conclusion.” There was a conflict of interest present which had to be considered in court as well, since Hartford was the plan insurer and administrator.  The appeals court found that Hartford abused its discretion and wrongfully denied Alexander her long term disability benefits.

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I contacted Dell & Schaefer after my insurance provider stated that they were coming to visit me at my home to see how I was doing. I was so worried about what this meant after being on claim with them for three years. I always felt like I was always waiting for the other shoe to drop with them after going through a very stressful claim application process. Gregory Dell promptly jumped in and got to work at creating a solution to streamline and ensure my claim was not in jeopardy.

The staff has worked with me every step of the way to make sure that the process of receiving my benefits is a positive one for me. I no longer dread dealing with my insurance claim representative as they handle everything for me. They clarified that I could also apply for SSDI and with their help I started receiving SSDI benefits within months. This firm has been a great advocate for me and I highly recommend them.

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