Lincoln LTD Denial Reversed for an Occupational Therapist that was Denied Benefits After 24 Months

Our now client came to us after she received a denial letter following her receipt of long term disability benefits (“LTD”) for a period of 24 months. This is very common as with any denied claim, at the 2-year mark is when many ongoing claims are denied. Why? Typically group long term disability insurance policies have special provisions that kick after 24 months of benefits are paid. First, most policies limit mental health claims to 24 months, thus if a claimant is disabled for such a condition, further benefits will be denied or such conditions will now no longer be considered when assessing whether a person is disabled. Secondly, and almost more importantly to a greater number of claimants, at the two-year mark what is means to be disabled totally changes.

For our client, both of these provision changes impacted her claim as not only did she suffer from some mental health issues (as well as physical issues), but the definition of disability that was governing her claim changed.

Under the policy governing this claim, to initially prove that one is disabled, they must merely prove that they are “unable to perform each of the main duties of their regular occupation.” However, after benefits are paid for 24 months, in order to remain on claim, they must then prove that that are “unable to perform each of the main duties of any occupation.”

This “Any Occupation” standard really opens up the possibilities for potential jobs an insurance company can state that a claimant can perform, however, this language is not without limitation. Typically, “any occupation” must take into account the person’s training, education and experience, and typically, this any occupation must be one that will pay the claimant 60% of their prior monthly earnings. Commonly, the insurance companies believe that “any occupation” is a sedentary occupation, which means one where a person just sits all day. Thus, the insurance companies almost act as if they believe a person can sit a few hours a day, then they are no longer disabled. However, this is not necessarily true.

For our client on this claim, employed previously as an Occupational Therapy Assistant for Advanced Homecare Management, her claim was initially a little bit easier as she merely had to prove that she could not do that job, which of course was not a sedentary job, but a skilled, medium level occupation that required a certain amount of lifting and usage of her strength. Due to her various diagnosed conditions which included significant cervical and lumbar spine issues, chronic fatigue syndrome and fibromyalgia, it was pretty easy to prove that she did not have the strength and ability to lift and move patients. Thus, when she initially applied for benefits, Lincoln, the disability insurance company, quickly approved her claim. And while benefits were ultimately paid for a period of 24 months, like it always does, Lincoln took a hard look at her case just before that Change in Definition of Disability was about to occur.

Lincoln’s 24 Month Review and Denial

Just before the 24-month mark, Lincoln did a few things. First, they had her claim reviewed by an in-house Nurse Disability Consultant. This employee nurse looked at some of the medical records and believed there was an opening to deny this claim. However, this nurse was smart enough to force Lincoln to do additional research before denying this claim and recommended that this claimant be sent for an Independent Medical Examination (“IME”) which was ultimately conducted by an Occupational Medicine doctor. Following receipt of the IME doctor’s report, Lincoln utilized the results and did what is known as a Transferable Skills Analysis. Essentially, Lincoln sent the opinion of the IME doctor to an employee known as a vocational consultant. This vocational consultant utilizes the restrictions and limitations of the IME doctor (which mind you, is an opinion that they paid for) and the gives a few qualifying occupations that they believe the claimant can perform based upon the IME doctor’s opinion and the claimants training, education and experience.

For our now client, Lincoln came up with 4 sedentary  occupations that they believe she was qualified to perform and that would apparently pay over 60% of her prior monthly earnings. Armed with this, Lincoln then sent a June 7, 2022 denial letter which conveyed its decision to deny continued LTD benefits beyond 24 months.

Knowing that there was just no way she could do a sedentary job especially in light of her back issues and significant pain issues, our now client came to us for assistance with an appeal.

Dell & Disability Lawyers Review, Additional Testing and Appeal

Upon being retained by our now client, Attorney Alexander Palamara hit the ground running to investigate this claim. Beyond ordering and reviewing the claim file from Lincoln, Attorney Palamara also ordered updated records and sent his now client for a Functional Capacity Evaluation (“FCE”). The results of his investigation were eye opening as it was clear that not only did Lincoln either overlook or ignore relevant medical data, but it turns out the IME was essentially a farce. Additionally, Mr. Palamara’s review of the medical records showed that there was a tremendous amount of objective evidence such as MRI results and X-rays which objectively proved our client’s complaints. Lastly, the results of the FCE which we sent our client to was clear that the independent physical therapist who conducted that Evaluation over the course of almost an entire work day came to the conclusion that our client was incapable of even working at a sedentary level.

The Appeal turned out to be simple. We first focused on the objective evidence found in the claim file, and summarized how such proved that this person could not to sedentary work. Beyond that, we then looked at the results of the Functional Capacity Evaluation and explained how this also proved that our client could not do sedentary work. Next, we then went to our client’s treating providers who have treated our client over the course of years. Each was nothing but supportive and wrote that our client could not maintain gainful employment. We finally quoted from the Social Security Administration’s Impartial Administrative Law Judge who only 4 months prior to Lincoln’s denial wrote that our client could not maintain gainful employment and approved Social Security Disability Benefits.

However, we did not stop there. Beyond proving our case beyond any reasonable doubt, we then finished our appeal by criticizing the actions of Lincoln before it denied this claim. In doing so, we spent a good amount of time focusing on the farce which was their Independent Medical Examination which they claimed to also include a Functional Capacity Evaluation. However, seeing how the IME doctor only spent a total of 13 minutes with our client, it was almost impossible for their hired doctor to truly have an idea into our client’s abilities and inabilities. We also noted how much objective evidence Lincoln overlooked and how it overlooked the decision of the Social Security Administration. We essentially left Lincoln no choice by to overturn its improper decision and we are ultimately happy to report that it did just that. 

Via a February 21, 2023 re-approval letter, Lincoln informed us that benefits were being reinstated with all back benefits owed being paid immediately and continuing benefits to be paid moving forward.

While our client is relieved to be back on claim, she knows that our firm will continue to do whatever it takes to keep her on claim until she is ready and able to return to work.

If you have been denied disability insurance benefits by Lincoln or any disability insurance carrier, never hesitate to reach out to Attorney Palamara for a free consultation and assessment of your claim.