Our client, a former Special Education Teacher, was brutally assaulted in a commercial gym by another gym patron that required brain surgery and resulted in a traumatic brain injury that left our client with severe cognitive problems, migraines, seizures, and post-traumatic stress disorder. Shortly after the attack our client filed a claim for disability insurance benefits through his county school district’s disability insurance policy with Lincoln. Given the nature and severity of his condition Lincoln quickly approved his short term disability claim and when it came time to transition to long term disability, approved that claim with no problem.
Similar to the overwhelming majority of employer provided disability policies, his policy through Lincoln provided benefits for the first 24 months in the event he was unable to perform the duties of his prior education, in this case that of a Special Education Teacher. For the first 18 months of long term disability it would seem that there would be no problem in continuing to receive his monthly disability benefit. However, in December of 2016, almost six full months before the definition of disability in his policy changed from the “own occupation” standard to the inability to perform the duties of “any occupation,” Lincoln advised our client that it had determined that he would no longer be disabled as of May 2017 and that his claim was being closed. According to the denial letter sent to our client, Lincoln argued that the available medical information, to include neuropsychological testing, failed to establish medically necessary restrictions and limitations that would prevent our client from working at a “sedentary” or “light” duty level as defined by the Department of Labor.
The Administrative Appeal
After receiving the denial letter our client contact Attorneys Dell & Schaefer and spoke with Attorney Stephen Jessup to represent him in filing his administrative appeal. Attorney Jessup obtained a copy of our client’s claim file from Lincoln and in doing so received a copy of the medical report conducted by Lincoln’s physician consultant. Per the denial letter Lincoln argues that the reviewing doctor’s report indicated a lack of evidence of disabling cognitive problems that would prevent our client from working. However, upon closer examination it became obvious that the physician consultant actually agreed with our client’s treatment providers that our client continued to experience cognitive limitations that resulted in deficits in attention, processing and organization skills, as well as the inability to effectively multi-task. As our client’s occupational skills existed solely in the realm of teaching Attorney Jessup argued that the ongoing cognitive problems documented in the neuropsychological evaluation would prevent him from returning to gainful employment.
Furthermore, Attorney Jessup argued against Lincoln’s position that the medical information on file evidenced the ability to work at a sedentary or light duty demand level. Attorney Jessup noted that our client’s claim has never been due to an inability to physically perform tasks, but rather solely on his inability to meet the cognitive/mental demands of work in his prior occupation and any other gainful occupation. After gathering additional supportive documents from our client’s treating physicians along with statements from friends and family Attorney Jessup submitted our client’s appeal.
Although it would seem clear to a reasonable mind that our client would not be able to work in any gainful capacity, Lincoln did everything it could to find a way to uphold its decision to deny the claim. During the course of the appeal review Lincoln required our client to undergo an Independent Medical Examination with a Neurologist. Unfortunately for Lincoln the IME doctor only verified what our client and his doctors had been saying all along- that our client is unable to work due to the lingering injuries and cognitive problems stemming from the assault that left him permanently injured.
With no other option, Lincoln notified Attorney Jessup that it was overturning the denial of our client’s claim for benefits, reinstating his claim, and issuing all benefits owed to date. Attorney Jessup continues to represent our client to best ensure that Lincoln will not terminate the benefit again.
Please feel free to contact our office to speak to one of our disability attorneys for a free consultation as it relates to any concerns you may have with your disability insurance claim.