As an attorney for clients who go up against disability insurance companies all over the country, I can tell you that the insurance contracts are often full of legalese and gibberish that most individuals don’t understand. Unfortunately, most individuals don’t understand even the communication they receive from the disability insurance companies, such as why their claim has been denied. According to the outcome of the case below, even a judge may find communication from the insurance company difficult to understand.
Nancy Love vs. National City Corporation Welfare Benefits Plan
Nancy Love worked for National City Corporation for two decades before she was forced to stop working. When Mrs. Love began experiencing dizziness, fatigue and blurred vision, she visited the doctor and was diagnosed with multiple sclerosis. Mrs. Love applied for and received short term benefits from the National City Corporation Welfare Benefits Plan, underwritten by Liberty Mutual. Short term disability benefits were for 18 months, and when Mrs. Love benefits expired, she applied for and received long-term disability benefits.
Mrs. Love received the disability benefits for three years before Liberty Mutual determined that she was no longer what the plan considered to be ‘disabled.’ According to the policy, an individual is considered disabled for the first two years if he or she is unable to perform their job but after the first two years, they’re only considered disabled if they’re unable to perform anyjob, including a job they could take classes and qualify for, etc.
Liberty Mutual Hired Physicians to Discredit Several of Love’s Attending Physicians
To first deny Love for any more disability benefits, Liberty Mutual relied on Doctor Jonathan Sands. Dr. Sands reviewed Love’s medical file and determined that although she most likely did have multiple sclerosis, there was no clinical attack noted, and that “no objective limitations in functional ability or capacity were noted.”
This report was sent to Love’s physician, who did not respond. Soon after, Mrs. Love’s benefits were terminated due to Dr. Sands’ assessment and Mrs. Love’s inability to provide information which supported her assertions that she was unable to perform any job due to her disability. Mrs. Love appealed Liberty Mutual’s denial, turning over more medical records, including a functional capacity evaluation, a vocational evaluation and a physical therapy evaluation. The next physician Liberty Mutual had to examine the case was Dr. Gerald Winkler. Dr. Winkler stated, after reviewing the files, that Mrs. Love was not totally disabled and could perform certain tasks, such as answering telephones, working at computers or dealing with the general public. Love’s appeal was denied.
Failure to Explain Sufficiently
Love filed a lawsuit in the Illinois Federal District Court against the insurance company, citing ERISA law and claiming:
- That the insurance company did not consider all medical evidence provided to them by Love, and;
- The insurance company did not fully explain why they had denied Mrs. Love her benefits.
The Illinois District Court ruled in favor of Liberty Mutual, pushing Love to appeal their decision to the Seventh Circuit Court of Appeals. Since ERISA requires all insurance companies who deny policyholders to “set forth the specific reasons for such denial, written in a manner calculated to be understood by the participant,” the appeal court felt that Liberty Mutual had not done so. The court found that neither the termination of benefits letter nor the appeal denial letter properly explained to Love why she would no longer be receiving disability benefits.
Another thing Dr.’s Sands or Dr. Winkler did not address was the contradiction they held with Mrs. Love’s attending physicians. Every physician that personally examined Mrs. Love felt that she was not able to work at any job, and that she was unable to perform even small tasks for more than a few hours at a time. Dr. Sands and Dr. Winkler did not address those issues. They did not go over the statements or medical tests and explain why they weren’t credible or able to be used as proof of Mrs. Love’s disabilities. Therefore, the court found that there was insufficient explanation on this part as well.
The case was remanded to Liberty Mutual with requirements to fully review the case of Mrs. Love and determine her eligibility for disability benefits in the fairest of ways. While this is a victory for Mrs. Love, the truth is that she should not have had to fight so long in order to get what she deserved in the first place. With as many physicians’s reports as Mrs. Love had – all stating her disability made it unable for her to work – she should not have had to fight so hard for what she deserved, but she did. Perhaps, the ruling in this case will make future cases easier for Libert Mutual policyholders who are unable to work and have credible medical support.