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Lincoln Approves Disability Benefits Following Second Appeal



Attorney Stephen JessupAuthor: Attorney Stephen Jessup

After over a yearlong fight with Lincoln Financial, our client, with the assistance of Attorney Stephen Jessup, was finally successful in securing her long term disability benefits following two levels of administrative appeals in response to Lincoln’s denials of her claim. Prior to filing for disability benefits under her employer’s group long term disability insurance policy with the Lincoln, our client worked as a quality assurance manager in the information technology (IT) department for her employer. A career in IT is one that requires critical thinking skills, attention to detail, organizational skills, and a level of physical ability to be able to move, carry, install and arrange computer and server equipment. Needless to say, our client had excelled in her career as evidenced by her position in management.

Prior to receiving a formal diagnosis of Multiple Sclerosis our client began to experience what she described as a growing history of clumsiness, falls, fatigue, difficulties concentrating, staying focused and remembering information. Despite these problems she continued to work and as her symptoms progressed she was finally diagnosed with MS following an MRI of her brain that identified several areas with lesions. In spite of her diagnosis she attempted to continue to work, but mounting mistakes, and increasing physical problems at work left her with little option but to file a claim for disability benefits.

Initial Approval

Early in the disability our client’s neurologist agreed that it would be best for her to take some time away from work to see if her MS related symptoms could be stabilized to the point that she would be able to return to full time work. However, as would unfortunately be the case, her doctor would not prove to be helpful in documenting her disability, or in supporting a long term disability claim. In the administration of her claim Lincoln required updated Attending Physician’s Statements from her treating neurologist, who after only three months of disability indicated that our client’s MS was sufficiently stable for her to return to work. Despite our client’s report of continued fatigue and cognitive problems, Lincoln only focused on her doctor’s opinion to the exclusion of other applicable information to deny her claim.

The First Appeal

Following the denial of her benefits our client contacted our office and spoke with Attorney Stephen Jessup. Initial review of the information raised concern for Attorney Jessup as in his experience a doctor who was not supportive of a claim for disability benefits would almost assuredly give the insurance carrier an easy win. Unfortunately, our client relayed to Attorney Jessup that her neurologist did not “believe” in disability if one was able to function on a relatively basic level. Attorney Jessup knew that it would be difficult to establish the claim for disability in Lincoln’s eyes as Lincoln was ultimately looking for ways to provide a “reasonable” review of her claim in order to satisfy legal requirements for its denial of benefits. To Attorney Jessup, nothing is typically more reasonable than agreeing with an insured’s doctor who is stating their patient is cleared for work.

In preparing the initial appeal the first priority was to discuss with our client the importance of finding a new doctor- not only for purposes of supporting her claim, but for purposes of providing an appropriate and adequate level of treatment for her condition. Next, Attorney Jessup knew that in light of her doctor’s prior opinions, additional objective testing would be needed in order to establish functional restrictions and limitations both physically and cognitively. To accomplish this goal Attorney Jessup arranged for our client to undergo a Functional Capacity Examination (FCE) to establish her physical restrictions and limitations as they related to her ability to perform at the physical demand level required of her occupation and a Neuropsychological Evaluation to establish any restrictions and limitations stemming from her cognitive difficulties. Unsurprisingly to both our client and Attorney Jessup, the FCE and neuropsychological examinations both resulted in objective medical restrictions and limitations both physically and cognitively that would prevent her from performing the main duties of her occupation as an IT Manager. Despite the results of testing and the objective evidence of impairment they provided, our client’s doctor would still not reconsider his position as it related to her disability. Given a short window of time with which to submit the appeal our client was not able to establish treatment with a new neurologist. Regardless, armed with compelling information of disability, Attorney Jessup submitted the appeal.

The Second Denial and Second Appeal

Despite the evidence of disability provided during the appeal, Lincoln’s review of our client’s appeal was essentially a rubber stamp of the initial denial as Lincoln and its medical reviewers only quoted and focused on the opinion initially expressed by her neurologist when the claim was denied. As Attorney Jessup had feared, the unwillingness of our client’s doctor to support her claim was proving to be a very large obstacle to overcome, regardless of the testing performed that quantified and qualified physical and cognitive restrictions and limitations. During the time that passed from the submission of the appeal to the denial of same our client was fortunate to begin treatment with a new neurologist in the same practice as her previous doctor who had recently retired. Despite the opinion held by his former colleague, our client’s new neurologist was very much supportive of our client’s claim for disability benefits. Attorney Jessup knew that even with the support of the new doctor that there would still be difficulty in proving to Lincoln that our client was disabled back to the date of the original denial due in large part to the opinions expressed by her former neurologist.

Unlike the vast majority of disability insurance carriers, Lincoln requires a mandatory second appeal. To some this can be a burdensome delay, but due to the fact the appeal is mandatory and not voluntary, Lincoln is required to have an insured’s entire file reviewed by new medical reviewers (as opposed to voluntary appeals where the carrier can send any updated information to the initial appeal review doctor). Due to this fact Attorney Jessup knew our client stood a much better chance in having her file reviewed free of prior bias and opinion during the second appeal process with Lincoln. Attorney Jessup coordinated with our client’s new neurologist to provide medical opinion that (1) supported and endorsed the findings of the FCE and neuropsychological exam and (2) would correlate the medical opinion as being reasonable and applicable to the time period of the initial denial, some eight months prior. Armed with strong doctor support and crafted argument further addressing restrictions and limitations since the initial denial of benefits Attorney Jessup submitted our client’s appeal.

Approval

After the appeal was submitted Lincoln still continued to delay its decision on the second appeal. Approximately 45 days into the review Lincoln advised our office that our client’s medical records were still under medical review and additional time would be needed to finalize the review of the appeal. Finally, two months after the second appeal was submitted, and over one year from the initial denial, Lincoln notified our office it was approving our client’s claim for benefits, forwarding all back benefits due to date and placing her back on claim.

Shortly after her claim was approved Lincoln required updated claim forms as well as a phone interview to determine current restrictions and limitations along with our client’s activities of daily living. Although our client has finally received some breathing room in light of her award of benefits, Lincoln is already applying pressure as our client’s claim will soon face the review from “own” to “any” occupation under her policy. Working with our client and her doctors, Attorney Jessup is already preparing for this review to ensure our client has the best chance to continue to receive her disability benefits.

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If you are having difficulties with your disability insurance carrier or have any questions regarding your claim for benefits please feel free to contact our office to speak with one of our disability insurance attorneys.