Our client, Ms. D, formerly worked as a professor for at a college. In January 2016 a number of co-morbid physical conditions and ailments forced Ms. D to stop working and submit her claim for disability benefits under her employer’s Long-Term Disability (“LTD”) Policy administered and funded by Lincoln. Under the employer’s disability policy Ms. D would be considered totally disabled if she was unable to perform the material and substantial duties of her regular occupation, which was defined as the occupation in which she was employed with her employer and was her primary source of earned income at the time of her disability.
After submitting her claim and all the necessary and relevant supporting documentation, Lincoln denied her LTD benefits on the basis that she allegedly did not meet the policy definition of disability. Specifically, Lincoln determined that “the medical documentation contained in [her] claim file does not support any restrictions or limitations that would preclude [her] from performing the main duties of [her] own occupation.” After receiving the denial, Ms. D contacted Dell & Schaefer and discussed her case with Attorney Jay Symonds. Attorney Symonds identified several significant issues in Lincoln’s denial letter and in the evidence it relied on and agreed to prepare and submit Ms. D’s ERISA appeal with the assistance of his appeal team.
The LTD appeal addressed all of Lincoln’s short-comings and reasons for denial, with a special focus on the medical records on and around the date of Lincoln’s denial. The appeal next addressed the Ms. D’s reasonable expectation that the physician chosen by Lincoln would have the appropriate qualifications to conduct the review, which was not the case. The physician chosen was not qualified to assess or evaluate Ms. D’s complex medical conditions and therefore the medical review was, on its face, clearly unreasonable and did not constitute a full and fair review. As for the purported opinions, several statements in the reviewer’s “analysis” made clear that he was simply reciting generalized, out dated, and pejorative, comments associated with Ms. D’s medical conditions to support his otherwise unqualified opinions. For example, the reviewer made several stereotypical comments as it relates to Ms. D’s fibromyalgia was a controversial and self-perpetuating diagnosis. In short, Lincoln’s reliance on a the medical reviewer’s opinions as the primary basis on which to deny benefits was incorrect as well as arbitrary and capricious and was not the result of a full, fair, thorough and honest investigation of Ms. D’s claim.
Several months later, and after reviewing the appeal and hundreds of pages of exhibits and medical records, the parties agreed to a negotiated financial resolution of Ms. D’s claim. Feel free to call our disability attorneys for a free consultation on this or any matter relevant to your disability claim.