Often, one cannot help but feel that an insurance company has denied their claim for disability benefits for the sole purpose of forcing them back to work so the company does not have to pay benefits. The expression “starve into submission” is appropriate when describing this insurance company tactic. With no source of income many people have no other option and do just that. For our client this was a grim reality that took almost two years of fighting for her disability benefit before Lincoln finally approved her claim.
Short Term Disability
In mid-2012, our client, a Quality Assurance Analyst for a credit union who was suffering from Chronic Low Back Pain following a lumbar surgery, Spinal Stenosis, Osteoarthritis of the knees, Fibromyalgia and Migraines, contacted our Office to discuss a recent denial of her claim for short term disability benefits under her employer’s group disability policy. Pursuant to a May 2012 denial letter Lincoln determined that the medical evidence submitted in furtherance of her claim failed to support our client’s inability to perform the material and substantial duties of her occupation beyond January 4, 2012. The delay between January and May of course begged the question, what took Lincoln almost four and a half months to reach this decision? Distraught and unable to work she contacted our office and spoke with Attorney Stephen Jessup.
Attorney Jessup’s review of the denial letter led him to believe that Lincoln’s delay in rendering the decision was not by accident. Lincoln’s position was that the clinical evidence as of January 4, 2012, did not support disability – thus creating a situation where our client would have to “prove” disability for a prior time frame based on medical documentation that would not be contemporaneous to the timeframe forming the basis of the denial. Had she received the denial letter shortly after January 4, 2012, contemporaneous medical evidence could have been more readily proffered to counter Lincoln’s decision that she was not entitled to benefits.
The First Appeal
In appealing Lincoln’s adverse determination, Attorney Jessup had our client undergo a functional capacity evaluation (FCE) to better determine her physical ability to work in light of her multiple physical medical conditions. The results of the FCE indicated markedly reduced range of motion, strength deficits and functional restrictions that would prevent her from working in a sedentary category occupation. Armed with this objective testing and additional support from her doctors, Attorney Jessup submitted our client’s appeal. Despite the additional evidence of disability Lincoln wasted no time in denying her initial appeal.
In denying her claim on the first appeal, Lincoln fell back to its argument that the medical evidence provided on appeal was not indicative of our client’s physical restrictions and limitations as of January 4, 2012, thus confirming Attorney Jessup’s opinion as to the initial delay in rendering a claim decision.
The Second Appeal
More often than not Lincoln group disability policies require a second level of appeal before legal action can be initiated. Such was the case with our client. Attorney Jessup argued in the second appeal that due to the nature of our client’s medical conditions it would logically follow that by extrapolating the time backwards to January 2012 the results of the FCE submitted as part of the first appeal would be an accurate reflection of her physical restrictions and limitations as of January 4, 2012.
Suspicious of Lincoln’s prior actions and to protect and enforce all of our client’s rights, while preparing the second appeal of the short term disability claim Attorney Jessup submitted an application for benefits under our client’s Long Term Disability policy.
In keeping with its prior rationale for denying benefits, Lincoln again echoed the rationale contained in its initial denial letter to once again deny our client’s claim for short term disability benefits.
Long Term Disability
Our client was frustrated, upset and angry with Lincoln and their unwillingness to pay the benefits she was entitled to. She wished for nothing more than to be healthy enough to return to work as the financial strain on her family was becoming too great to bear. Attorney Jessup continued to advocate on her behalf, but prepared her for what he expected would be a denial of her long term disability benefits as receipt of her long term disability benefit was contingent on being disabled throughout the Elimination Period. According to her policy, the Elimination Period was the period of short term disability benefits. In light of the denial of short term disability benefits it was with little surprise that the claims manager for the Long Term Disability continued the broken record theme and rubberstamped the denial based on the rationale contained in Lincoln’s prior denials.
By this point our client had little faith in Lincoln or in the chance of ever receiving benefits. As with her short term disability policy, she was required under the law to submit an appeal of the denial of her claim for long term disability benefits. Attorney Jessup continued to argue the sufficiency of the medical documentation that supported our client’s claim. However, by this point a new complication to the claim was occurring, which is common to many claimants who find their health benefits terminated following a denial of disability benefits – she was not able to afford to go to the doctor. As such, it was difficult to provide any new medical information to support a current disability, yet alone get additional doctor support back to January of 2012.
As fate would have it our client was awarded Social Security benefits during the timeframe of the long term administrative appeal process. Armed with Social Security ruling, but knowing Lincoln’s argument as to no contemporaneous proof of disability in January 2012 would still be at issue, Attorney Jessup submitted our client’s appeal for long term disability benefits.
Finally, after almost two years with no disability benefit, our client was approved for long term disability benefits. Attorney Jessup then took the long term disability award letter and contacted the short term disability department to demand payment for the remainder of her short term disability benefits.
Our client is now on claim, has received all back benefits owed and will be receiving her monthly disability benefit checks. However, the fight is far from over as the change in occupational definition is looming in the immediate future.
Don’t Give Up.
Our client’s claim is a testament to the difficulty a claimant can face in trying to secure a disability benefit. Insurance companies hope that you stop pursuing your claim for benefits and/or return to work as it nullifies their liability to you under a disability policy.
As was the case with our client, the fight was long and unpleasant, but unable to return to work she had no choice but to continue to fight. If your disability claim has been denied by your insurance company please contact our office to discuss how we may be able to assist you in fighting for your benefits.
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