Lincoln National LTD Denial for Pre-Existing Condition Reversed on Appeal
On December 8th of 2020, a new employee at ServerCentral, now known as Deft, a well-known IT infrastructure provider, found himself in the Emergency Room due to facial numbness and confusion. This ER visit was unfortunately not something new for him as he had just been there two weeks prior in late November due to a headache and dizziness. With this visit of December 8th, he was diagnosed as suffering from a transient ischemic attack. Unfortunately, on December 23, 2020, he again found himself back in the hospital. This time he was diagnosed as suffering from a Cerebrovascular Accident (CVA), which is commonly known as a stroke. It was quite a few weeks for man who should have been celebrating his 60th birthday which occurred on December 13, 2020. Instead, he was essentially fighting for his life and trying to figure out what the heck was going on with his body.
Following this series of events, this man quickly realized that he could not work. Thankfully, his employment with ServerCentral brought with it coverage under a long term disability (“LTD”) policy and this policy was with Lincoln National Life Insurance Company. Thinking he would have no issue getting approved as his records were quite clear that he was disabled, he quickly filed a claim. Unfortunately, Lincoln refused to pay benefits.
Now it is certainly understandable why Lincoln took a hard look at this claim. This employee of ServerCentral was a new hire and only a covered person under the policy since August 1, 2020. Thus, he was barely covered for 4 months when he was already making this claim. Additionally, he was a high-income earner, thus Lincoln had every motivation to find a way not to pay benefits. And that is what they in fact did.
Following his application for benefits, Lincoln took some time in reviewing this claim. They gathered a lot of medical records which included not only his hospital and doctor visits during and after his stroke, but they also gathered records from before this man was even a covered person under the policy. The motivation for doing such was to find a way to deny this claim as a Pre-Existing Condition.
Most Group Long Term Disability Insurance policies will typically not pay benefits if a claim for disability is caused by a pre-existing condition. Typical language of the policies will define a “pre-existing condition” as “a sickness or injury for which the insured employee received treatment within 3 months prior to the insured employee’s effective date.” They further define “treatment” as meaning “consultation, care or service provided by a Physician. It includes diagnostic measures and the prescription, refill of prescription, or taking of any prescribed drugs or medicines.”
Thus, if an insurance company gets records that show that you treated with a doctor or even took medications for a condition that led to you filing a claim for disability benefits, then the policy gives the insurance company the option of denying the claim as a pre-existing condition. However, keep in mind that the time period where the insurance company can look at records might be limited. This time period is often called the “look back period.” Under ServerCentral’s LTD Policy, the look back period was a 3 month period that occurred just prior to the beginning of coverage. Since this man’s coverage began on August 1, 2020, the look back period for this claim was the period of May 1, 2020 to August 1, 2020.
Following its review of the medical records including records from the look back period, Lincoln issued a decision to deny this man’s claim. This decision was conveyed via a June 16, 2021 denial letter. And yes, Lincoln justification in denying this claim was that his stroke was a pre-existing condition. At first blush, one might think, “how the heck can a stroke be a pre-existing condition as they typically happen spontaneously?” Lincoln answered this question by stating that “hypercholesterolemia and hypertension are known risk factors for development of cerebrovascular accident.” It then stated that our now client had a “clinical history that (included) prolonged hypercholesterolemia and hypertension treatment…” It was therefore Lincoln’s argument that such “were contributing factors (to) his current disabling condition.”
Following his receipt of this denial letter, our now client found our firm and spoke with Attorney Alexander Palamara. A quick call and a review of the denial letter quickly convinced Attorney Palamara that Lincoln’s denial letter was irrational and clearly monetarily motivated. It was almost hard to fathom that Lincoln was denying this claim because this man had somewhat high cholesterol and hypertension during the look back period and took medication for such.
Questions Regarding Lincoln’s Nonsensical Denial
Please keep in mind that the CDC notes that “about 38% of American adults have high cholesterol (total blood cholesterol > 200 mg/dl).” https://www.cdc.gov/cholesterol/index.htm. Additionally, the CD reports that 28% of American adults over age 40 take a cholesterol-lowering medication. https://www.cdc.gov/nchs/products/databriefs/db177.htm. Thus, it appears with this denial letter that Lincoln was stating that it expects that a great percentage of Americans will have strokes and thus they cannot file a claim under any of its group LTD policies if they do so within the first year of coverage. Or perhaps Lincoln was admitting that it isn’t covering 38% or 28% of American adults under their policies should they have strokes during their first year of LTD coverage. If this is the case, then insureds must be informed of such and language must be included in the policies issued by Lincoln since this standard has not been conveyed to any of its insureds. Additionally, each state’s insurance commissioners should be advised of Lincoln’s internal claim procedures and guidelines as this is something that they should be aware of. If 38% of adults covered by Lincoln are at risk of being denied and having no disability coverage based upon false assumptions relied upon by Lincoln, then insurance commissioners, insureds and the media have a right to know.
It is admittedly true that certain lifestyle factors increase your risk of stroke. Such includes high blood pressure, smoking, diabetes, high blood cholesterol levels, heavy drinking, high salt and high fat diet and lack of exercise. However, it is not true that “hypercholesterolemia and hypertension treatment” can be “contributing factors.” In fact, such treatment is designed to lower hypercholesterolemia and hypertension. But either way, having hypercholesterolemia and hypertension does not mean one will have a stroke. Furthermore, is it Lincoln’s intent to deny all people who suffer strokes with the above cited lifestyle factors? For instance, is it Lincoln’s intent to deny all smokers’ claims should they have a cerebrovascular incident in the first year of coverage? Will Lincoln also be denying ex-smokers who chew Nicorette rather than smoke? Will Lincoln also being denying claims for overweight people that suffer strokes? If so, what is the standard? Is there a certain BMI that insureds need to be aware of? Or what about drinkers? Is there a limit to how many drinks a day or week a covered person can have? If Lincoln finds out a person has more than 7 drinks a week, will their LTD claim be denied if they suffer a stroke in the first year of coverage? Or if someone hates exercising, will they be disqualified from benefits if they have a stroke before the first year of coverage has ended? Of course not, as there is no way to prove that heavy drinking or smoking or lack of exercise has caused the stroke.
The Administrative Appeal filed by Attorney Palamara
All of these questions were posed to Lincoln in the Administrative Appeal drafted and filed by Attorney Palamara. In addition to challenging Lincoln’s ridiculous justification to deny this claim, the appeal did three other things: 1) it challenged the review and opinion by Lincoln’s “independent” consultant Dr. Guru Motgi; 2) it gathered support of the treating providers who refuted the idea that this man’s stroke was a result of a pre-existing condition; and 3) it proved that the man was now disabled as a result of his stroke.
With regards to Dr. Motgi’s report, it is important to note that this consultant wrote that “it is likely given the claimant’s clinical history that prolonged hypercholesterolemia and hypertension were contributing factors to his current disabling condition.” Thus, this consultant’s entire conclusion was strictly an ASSUMPTION. It was a mere guess. Additionally, the appeal pointed out the medical documentation that Dr. Motgi conveniently left out of his report which included a series of records that showed that his cholesterol levels were dropping based upon his treatment and a Brain CT of November 23, 2020 which showed that his ventricles and sulci were within normal limits. Thus, prior to his stroke in December 2020, this man had improved blood work and a normal CT scan. However, Dr. Motgi conveniently left his out of his report in order to assist Lincoln in arguing that this denial of benefits is justified as a pre-existing condition.
The opinions of the treating providers were even more convincing. Each of these doctors agreed that our now client did not suffer from a stroke, cerebral infraction or cerebral vascular during the look back period; Each doctor agreed that he was compliant with his medication; Each doctor agreed that if someone suffers with Hypercholesterolemia, it does not mean they will suffer from a stroke, cerebral infarction or CVA; Each doctor agreed that no testing showed that our client had any formation of plaque on his artery walls prior to his stroke in December 2020; and each doctor agreed that they did not believe that our client’s suffering of a cerebral infarction should be considered as a pre-existing condition.
Lastly, the appeal also showed with the help of medical records that the result of our client’s stroke in December of 2020 left him unable to perform the duties of his own occupation.
Approval of Benefits
Although it took Lincoln the full 90 days allowed under ERISA to render a decision on this claim, Lincoln ultimately did the correct thing and approved this man’s claim for benefits. In approving this man’s claim, Lincoln essentially agreed that his taking medications for cholesterol or hypertension should not be considered as justification to deny this claim as a pre-existing condition. While our client is relieved to be on claim, he knows that the fight will continue. However, he is comforted by the fact that our firm will do whatever it takes to keep him on claim.
If you have been denied by Lincoln or any insurance company, please do not hesitate to reach out to us at once. We always provide a free consultation to review and assess your claim. And if we are able to assist you, we will always do whatever it takes to get you any benefits you deserve.
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