Red Hat Sales Manager With Heart Disease Wins Lincoln Financial LTD Insurance Appeal While on the Heart Transplant List
Lincoln Financial looked at a man on the heart transplant list and decided he could go back to work. Our client was a strategic accounts manager at Red Hat in New Jersey when ventricular tachycardia, a dangerous heart rhythm that two ablations failed to control, forced him to stop working. Advanced heart failure and a long list of other cardiac conditions came with it.
In nearly two decades of practice, including hundreds of claims against Lincoln, attorney Cesar Gavidia had rarely seen an insurer turn away someone waiting for a new heart. Our long-term disability lawyers have faced denials like this many times, and we know how to take them apart. We appealed, and Lincoln reversed its decision.
How this appeal was won holds lessons for anyone whose doctors say the stress of work is dangerous to their health. If Lincoln or any other disability insurance company has denied your claim, speak with one of our lawyers. We represent claimants nationwide, and you pay no fee unless we recover your benefits.
Table Of Contents
- 1. Why this case matters for every Lincoln Financial claimant
- 2. A heart transplant candidate in a high-incentive sales job
- 3. Lincoln’s denial: a paper review that contradicted itself
- 4. Job stress and ventricular tachycardia: what Lincoln never weighed
- 5. Building the appeal from the claim file up
- 6. Lincoln reverses its denial
- 7. Speak with one of our lawyers today
Why This Case Matters for Every Lincoln Financial Claimant
Lincoln Financial denied long-term disability benefits to a sales account manager with heart failure and ventricular tachycardia while he was on the heart transplant list. Here is what every claimant should take from how we won it.
- Job stress is part of your occupation, even when the insurer ignores it. Lincoln judged a commission-driven sales role by its physical demands alone. If pressure, expectations or competition make your condition worse, your appeal has to prove it, and your specialist should explain in writing how those demands affect your health. In heart disease disability insurance claims, the strain of the job can matter as much as anything on an echocardiogram.
- Targeted questions to your own doctors can carry an appeal. We sent the treating specialists specific questions aimed at Lincoln’s reasoning, and their answers spelled out hours, weights and medical risk. Specific answers to an insurer’s specific reasoning are far harder to dismiss than general office notes.
- Take the claim file apart before you appeal. Lincoln’s own reviewer conceded our client was functionally impaired, then cleared him for light work. The file Lincoln produced was also missing statements from his cardiologist. In most ERISA lawsuits, the court reviews only the claim file, so the appeal is where you fix its gaps and expose its contradictions.
- Hold the insurer to what it has said about your health elsewhere. Lincoln had already dropped our client’s life insurance as too great a risk, then claimed he could work full time. A life insurance underwriting decision, a short-term disability approval or a premium waiver can expose a denial that contradicts it.
- An approved claim still needs watching. Insurers keep reviewing approved claims and often argue that a good day means you can work. Keep your treatment and records current, and prepare early for the change from own occupation to any occupation after 24 months of benefits.
A Heart Transplant Candidate in a High-Incentive Sales Job
Our client, 64 years old, was a strategic accounts manager at Red Hat, a high-incentive sales role built on commissions, high expectations and constant competition with colleagues. He loved the work. His heart could not keep up with it.
What His Cardiologists Documented
Ventricular tachycardia is a fast, abnormal heart rhythm that starts in the heart’s lower chambers and can become life-threatening. His had stopped responding to drugs used to control heart rhythm, and his implanted device recorded sustained episodes lasting five to six minutes. A catheter ablation, a procedure that scars the small areas of heart tissue sending faulty electrical signals, had already failed once. Shortly after he stopped working, a second ablation failed too.
The arrhythmia was only one part of a severe cardiac history, documented by a team of specialists at a nationally ranked academic heart center in New York City:
- Chronic systolic (congestive) heart failure (ICD-10 code I50.22), meaning the heart’s main pumping chamber squeezes too weakly to move enough blood through the body
- An echocardiogram showing left ventricular function moderately to severely decreased, severe enlargement of the left atrium and moderately reduced right ventricular function, meaning both sides of the heart were pumping weakly and the upper left chamber had stretched under the strain
- Ischemic cardiomyopathy (ICD-10 code I25.5), heart muscle damage caused by reduced blood flow, and coronary artery disease, with a prior heart attack treated with a stent; bypass surgery was ruled out because of a coronary deformity
- An implantable cardioverter-defibrillator, a device that shocks the heart back into a normal rhythm, followed later by a pacemaker
- A hospital admission for cardiogenic shock, a state in which the heart cannot pump enough blood to keep the body’s organs working
- Type 2 diabetes with complications, hypertension and high cholesterol
Can you get long-term disability insurance benefits for heart failure? Yes, when the medical record shows how the condition stops you from doing your job, and this record left no room for doubt. He had been listed as a heart transplant candidate for nearly two years before he stopped working. A transplant listing is reserved for patients with end-stage heart disease whose treatment options are running out.
Within days of his last day at work, his treating cardiologist documented these restrictions:
- Lifting up to 5 pounds, for up to 3 hours a day
- Carrying up to 2 pounds, for up to 3 hours a day
- Sitting up to 4 hours a day
- Standing and walking up to 2 hours a day
- Never kneeling, climbing, squatting, stooping, bending or reaching
The Policy Terms Lincoln Applied
After months of short-term disability benefits, his claim moved to long-term disability coverage under his employer’s group policy with The Lincoln National Life Insurance Company (Lincoln Financial). Approved for short-term disability but denied long-term disability? That is exactly what happened here. The long-term claim is a separate review under its own policy definition, and short-term approval guarantees nothing.
An elimination period is the waiting period a claimant must remain disabled before long-term disability benefits begin; under this policy, it was 180 days. Under an own-occupation definition of disability, a claimant qualifies for benefits if he cannot perform the material and substantial duties of his own occupation, even if he could do some other job.
This policy applied that definition for the first 24 months and let Lincoln measure his occupation “as it is normally performed in the national economy.” After that, the policy switches to an any-occupation definition, which asks whether a claimant can perform any job he is reasonably fitted for by training, education, experience, age and physical and mental capacity.
Lincoln’s Denial: A Paper Review That Contradicted Itself
Nobody from Lincoln examined our client before it denied his long-term disability claim. A paper review, also called a file review or peer review, is an evaluation in which an insurance company’s doctor judges a claimant’s ability to work from records alone, without ever examining the person. Being denied long-term disability benefits based on a paper review is something we see over and over again.
Lincoln hired Dr. Andre Akhondi, a cardiologist board certified in cardiovascular disease, to review the file. Senior Claims Examiner Kevin N. then signed a denial letter that copied large parts of Dr. Akhondi’s report. Paper reviews were behind the termination in our Lincoln appeal for a Hitachi Energy project manager with coronary artery disease, a decision we also reversed.
What Lincoln’s Own Reviewer Conceded
Dr. Akhondi’s report reads like a case for approval. He acknowledged ventricular tachycardia occurring at rest and with minimal exertion, two ablations and a badly weakened heart muscle. Then he wrote: “Despite treatment modifications, his symptoms continued to be refractory.” Refractory means nothing his doctors tried had worked.
He went further, concluding that “the claimant is conclusively impaired from a functional standpoint.”
Then He Cleared Him for Light Work
Light work generally means lifting up to 20 pounds with a good deal of standing or walking. Outside a single week of recovery after the second ablation, Dr. Akhondi assigned these restrictions:
- Sitting: unrestricted
- Standing: frequently
- Walking: occasionally
- Lifting, carrying, pushing and pulling: up to 20 pounds occasionally
- Keep magnets at least six inches from the implanted device
In practical terms, Lincoln’s reviewer said a man whose heart races into a dangerous rhythm at rest could handle a full day of light physical work, as long as he stayed away from magnets. He brushed aside every treating opinion with one conclusory line about the absence of clinical abnormalities severe enough to prevent work. That is an assumption, not a fact.
Same Job, a Different Employer
Lincoln’s vocational analysis was no stronger. A vocational analysis is an insurer’s assessment of what an occupation demands and whether a claimant can still meet those demands. Rather than reassess the job after the peer review, Lincoln relied on an earlier Occupational Analysis by vocational consultant Hanna D., which classified the role as a sedentary High Incentive Sales Account Manager position.
The denial letter described the physical demands of our client’s own job, then described the same occupation as performed in the national economy, in identical words. Its conclusion: “Therefore, you are capable of performing your occupation with a different employer.” Same duties. Same demands. A different employer. Lincoln never explained what would change, and it never mentioned stress at all.
Job Stress and Ventricular Tachycardia: What Lincoln Never Weighed
Does job stress count in a long-term disability claim? It does when stress is what makes the work dangerous. The reality is that a high-incentive sales role is defined as much by pressure as by posture, and Lincoln measured only the posture.
As Cesar wrote in the appeal, “the ability to perform work at a given exertional level does not equate to the ability to perform the material and substantial duties of a specific occupation, particularly one that is cognitively demanding, stress-intensive, and requires sustained reliability and performance.”
Our client’s treating electrophysiologist, a cardiologist who specializes in the heart’s electrical system, answered our questions in a written statement. She made the connection Lincoln refused to make:
- His ventricular tachycardia kept recurring despite aggressive medical therapy and two catheter ablations
- His condition could look stable at times but was inherently variable and could worsen with physical or emotional stress
- Stress in a high-pressure environment created a meaningful risk of arrhythmias requiring intervention from his defibrillator, as well as cardiac decompensation
- Continued work in a high-stress environment would harm his health and could raise the risk of serious adverse cardiac events
Cardiac decompensation is the point at which a failing heart can no longer keep up with the body’s needs. Put simply, the pressure of his job could trigger the very rhythm his defibrillator exists to stop, or push his heart past what it could handle.
That opinion has research behind it. A study published in Circulation found that emotional and physical stressors can trigger ventricular arrhythmias in patients with implanted defibrillators, with anger and physical exertion standing out as triggers.
Building the Appeal From the Claim File Up
Can you appeal a Lincoln Financial long-term disability denial? Yes, and under most group policies you must. An ERISA administrative appeal is the formal review a claimant must request from the insurance company before suing over a denied group long-term disability insurance claim, and federal law requires a full and fair review. It is also the last real chance to add evidence to the record.
Taking the Claim File Apart
Cesar started by taking Lincoln’s claim file apart. ERISA regulations give every claimant the right to copies of all documents relevant to the claim, free of charge. The file exposed problems the denial letter never mentioned:
- Dr. Akhondi wrote that no restrictions had been identified from the date our client stopped working, though the treating cardiologist’s restrictions sat in the same file
- Two statements from the treating cardiologist were missing from the file Lincoln produced; we could cite them only through Dr. Akhondi’s own summary
- Lincoln’s vocational analysis ignored even its own reviewer’s magnet restriction, which carries real consequences in a modern workplace
Requesting the file is a core step in appealing a long-term disability benefit denial, and it is where Lincoln’s case started to come apart.
Specialists Who Put It in Writing
Our client had something many claimants do not: a team of specialists willing to answer questions in writing. Cesar sent them targeted questions aimed squarely at Lincoln’s reasoning. Along with the electrophysiologist’s statement, the cardiology team completed a capacity questionnaire that put numbers on his limits in an eight-hour workday:
- Sitting: about 2 hours total
- Standing and walking: about 2 hours total
- A 5-minute walking break every 60 minutes
- Must be able to shift positions at will
- Lifting: 10 pounds occasionally and less than 10 pounds frequently
The team added: “Our main concern would be physical/emotional stressors that would precipitate ventricular tachycardia as patient feels palpitations when he feels emotionally stressed.”
Sedentary work is the least physically demanding category of work: it is done mostly while sitting, with lifting limited to 10 pounds. Lincoln’s own denial letter states that sedentary work “involves sitting most of the time,” consistent with the federal definition of sedentary work. Two hours of sitting is not most of an eight-hour day. Our client could not sustain even a desk job, let alone a high-pressure sales role.
Cooperation like this is not guaranteed. Many treating doctors refuse to fill out insurance forms, and then the evidence has to come from outside testing. A functional capacity evaluation (FCE) is a hands-on test of how long a person can sit, stand, lift and keep working. An FCE showing he could sit only about 2.5 hours a day anchored our Lincoln appeal for a Hitachi America HR advisor with cardiac stent stenosis, a denial we also reversed.
Lincoln Had Already Called Him Too Risky to Insure
Well before he stopped working, Lincoln terminated our client’s employee life insurance coverage because it considered him too great a risk to insure. Now the same insurer said he could work full time. As Cesar put it in the appeal: “These positions cannot be reconciled.”
An insurer cannot treat a man as an uninsurable mortality risk on one policy and a capable full-time worker on another. Life insurance and long-term disability decisions are closely linked; a denied waiver of life insurance premium often signals that a long-term disability denial is coming.
Lincoln Reverses Its Denial
Faced with its reviewer’s own words, a vocational analysis blind to stress, and specialists who explained exactly why high-pressure work endangered our client’s life, Lincoln reversed its decision and approved his long-term disability benefits.
His heart did not get any better between Lincoln’s denial and its reversal. What changed was the evidence in front of Lincoln and the way it was presented. Without that, Lincoln would have counted on a seriously ill man simply going away.
We continue to monitor the claim. An insurer willing to deny a transplant candidate once will look for another opening, and when it does, the record will already be built.
Speak With One of Our Lawyers Today
As Cesar wrote in the appeal, “Had Lincoln conducted a full and fair review, it could have reached only one conclusion.” In the end, it did.
If Lincoln Financial has denied your long-term disability claim, the clock is already running. ERISA rules give you at least 180 days to appeal a denied long-term disability claim, and what you submit in that window may be the only evidence a court ever sees. Do not face that deadline alone.
Our disability insurance lawyers have represented claimants against every major insurer since 1979. We have helped tens of thousands of people and recovered more than $2 billion in benefits. We represent clients nationwide, and you pay no fee unless we win your benefits. Get a free consultation with our long-term disability lawyers today.
