Lincoln Approves Long Term Disability Benefits After Four Year Fight

With financial protections afforded to disability insurance companies under ERISA that insulate them from extra contractual damages there is very little financial disincentive to deny long term disability benefits to an insured. This is especially true of disability applicants who are high wage earners whose resulting monthly disability benefits are extremely high. In our experience, insurance companies will go to great lengths to establish a “reasonable” basis to deny a claim in hopes that the insured will either give up on the claim, or eventually settle a case in court for a steeply reduced value. The actions taken by Lincoln during the course of our client’s claim review is a prime example of this unfortunate tendency to deny and draw out the process to almost unbearable lengths.

Prior to filing for disability, our client was a successful emergency medicine doctor for a large hospital system in the Pacific Northwest who suffered from multiple sleep disorders that greatly affected his ability to work with any semblance of reasonable consistency. Given the fact he worked in an emergency room setting this was something that was unacceptable to the hospital from a logistics standpoint, not to mention from a patient care/safety standpoint. As his condition worsened so did his ability to work, and in turn his relationship with his hospital became increasingly contentious. He was continuously written up, had conflicts with his colleagues, and was placed on multiple probationary programs within the hospital in order to maintain his job. As restful and restorative sleep continued to elude him and compound his difficulties at work, his behavior became so erratic, according to work records, that his employer felt he may be under the influence of substances. Ultimately, the relationship with the hospital became so fractured that following the end of a shift the hospital demanded he submit to a drug urine test and when he refused the hospital fired him on the spot.

Initially he did not file for disability benefits as his intentions were to get his sleep disorders under control so he could return to work again. However, as time went on it became obvious to him that he was in no position to return to his former occupation. Over a year after being fired by his employer he contacted Lincoln to initiate a claim for disability benefits retroactive to his last day worked. As the policy requires that notice of claim be provided within 30 days of disability Lincoln could have rejected the application, but to its credit accepted the application despite the late notice.

Claim Review

The claim review itself took an exceedingly long time due in part to the time that had lapsed since the indicated date of disability and issues with obtaining information. Complicating the situation further was the fact that our client and his former employer were not on good terms, which impacted and delayed getting information to Lincoln related to his employment. As the claim review dragged on our client contacted our office to speak with Attorney Stephen Jessup, to whom he was referred to by a fellow doctor and client of Attorney Jessup, who had his claim denial overturned following an appeal submitted by Attorney Jessup. Although Attorney Jessup and our client consulted on multiple occasions regarding the claim, our client had decided that he would pursue the matter on his own and would reach out to Attorney Jessup after a decision had been made on his claim.

The review culminated in our client contacting Attorney Jessup in early 2020, and notifying him that the claims manager had emailed him to advise him that he was recommending that the claim be approved. The claims manager also indicated in the email to the claimant that due to the benefit amount and back benefits owed that the file would have to be signed off on by a supervisor before benefits could be paid. Attorney Jessup knew that this was common practice with large benefit claims and advised the doctor as much. However, as several weeks passed it became apparent that the supervisor was not so inclined to sign off on the claim approval. Another month went by and Lincoln finally advised our client that it was denying his claim for benefits and in doing so argued that he was not disabled as of his last day worked. At his wits end, our client formally hired Attorney Jessup to take over the fight with Lincoln and file his administrative appeal.

The Appeal

When Attorney Jessup received the claim file from Lincoln it was in excess of 6,000 pages largely due on account of the fact that the date of disability was nearly three years prior. The amount of medical and occupational information was staggering, but even more so were Lincoln’s attempts to deny the claim. Attorney Jessup focused his attention on the medical file reviews as it was highly suspect that the claims manager would indicate a recommendation for approval only to have the claim denied by the supervisor. This led Attorney Jessup to believe that the medical reviews conducted by Lincoln likely supported our client’s disability. Low and behold, that was exactly the situation. Of the four medical file reviews performed all of the doctors found restrictions and limitations that would prevent our client from performing his occupational duties as an emergency medicine doctor. This was one of the first times in Attorney Jessup’s twelve years of experience that the claims department summarily ignored its doctors opinions and issued a denial.

Lincoln was trying to win on a technicality- the only “reasonable” basis it could find to deny our client’s disability claim. The supervisor’s basis for denial was predicated on the arguments that (1) our client had been able to work despite his medical conditions (2) that reasonable accommodations had been made to allow him to work a flex schedule (3) that he had worked a full day on his last day worked and (4) that he was not fired because of an inability to perform his job duties cause by his medical conditions, but rather because he refused to submit to a drug test. Therefore, Lincoln argued that his medical conditions were not the reason of his termination and ultimately not the reason he was not able to perform the material and substantial duties of his occupation.

In Attorney Jessup’s opinion, Lincoln not only decided to put blinders on, but also to bury its head in the sand. The claim file provided to Attorney Jessup contained a multitude of documents from the hospital related to our client’s work related problems and misconduct, all of which pointed to and referenced our client’s sleep disorders – being late for work, sleeping on shift, being incoherent or unable to concentrate, etc. When Attorney Jessup compared the dates of the performance evaluations with our client’s medical records there was a clear nexus between our client’s documented sleep disorders and his poor work performance. To Attorney Jessup it could not be more clear that the reason why our client’s professional career suffered so greatly was on account of his inability to obtain restful or restorative sleep.

Reviewing the medical and occupational information contained in our client’s file it was also clear to Attorney Jessup that the reason our client’s claim was being denied was due to the simple fact that Lincoln did not want to pay him nearly four years in back benefits, which was an incredibly substantial amount. Knowing that it would not be responsible for extra contractual damages, pain and suffering, bad faith or any other cause of action on account of a denial, Lincoln had nothing to lose in denying the claim.

Attorney Jessup compiled, presented and argued all the information in support of our client’s rights to disability, and submitted a 125 page appeal letter that summarily attacked Lincoln’s denial. However, Lincoln was not going to give up so easily. Just prior to the 45 day deadline with which to provide a response to the appeal, Lincoln exercised its right to a 45 day extension with which to render a decision. In doing so, Lincoln argued that our client’s file was under a medical review that had not yet been completed. Given the fact that four of Lincoln’s doctors had already determined our client to be disabled, Attorney Jessup was confident that based on the strength of the appeal and the information in the file that any current reviewing doctor would find the same. On the very last day of the 45 day extension, nearly four years after he stopped working, Lincoln sent notice to Attorney Jessup that it was approving our client’s claim for benefits.

Do Not Give Up

Attorney Jessup believes that the insurance industry attempts to turn disability claims into a war of attrition meant to wear the insured down in hopes that they will give up. Sadly, this happens all too often, and Attorney Jessup encourages claimants to stay in the fight as there is always something to gain in the end. If your insurance carrier has denied your claim or is dragging its feet in rendering a decision do not hesitate to contact our office to speak with one of our disability attorneys.