Our client, Mr. E, formerly worked as an Escalation Engineer for a national data services and data management company. For many years Mr. E suffered from chronic debilitating effects of multiple physical conditions and ailments, including Chronic Intractable Migraines, which left him with debilitating physical and cognitive impairments. Mr. E was unwilling to give up his career and worked as long as he possibly could. As a result of his serious medical conditions and associated restrictions and limitations, Mr. E was forced to stop working in May of 2017 and apply for disability benefits under his company’s Short and Long Term Disability (LTD) Policies, both of which were administered and funded by Lincoln.
Lincoln found Mr. E to be totally disabled and approved his STD claim through the 90-day maximum benefit period which ended in August 2017. With the expiration of the STD benefits Mr. E’s claim was submitted for continued payment under Lincoln’s LTD Policy, with the same definition of disability. After paying Mr. E LTD benefits for more than 1 year, Lincoln denied further benefits effective September 2018 on the basis that he allegedly no longer met the Policy definition of “Disability.” Specifically, Lincoln determined that “[Mr. E] can perform the substantial and material acts of [his] occupation.” After receiving the denial, Mr. E contacted Dell & Schaefer and discussed his case with Attorney Jay Symonds, who identified several significant issues in Lincoln’s denial letter and in the evidence it relied on and agreed to prepare and submit Mr. E’s ERISA appeal with the assistance of his appeal team.
The appeal addressed all of Lincoln’s short-comings and reasons for denial. In particular, Lincoln ignored key medical records which clearly established that Mr. E had undergone multiple brain surgeries due to a pituitary tumor which lead to his development of debilitating, incapacitating headaches (migraines). The records also confirmed that Mr. E’s headaches did not change following surgery and radiation for the tumor. Rather, Mr. E suffers from multiple headaches per week that can last several days. Subsequent neurologic examinations were abnormal with anxious and stammering speech and although Botox treatments provided some relief his debilitating headaches continued. Mr. E was then referred from an MRI of the brain and stem. The MRI confirmed the presence of enhancing tissue within the sella turcica, which represented residual pituitary tissue/tumor.
Next the appeal addresses Lincoln’s failure to properly and accurately assess the material and substantial duties of Mr. E’s occupation as an Escalation Engineer. Specifically, Lincoln’s vocational reviewer incorrectly and unreasonably considered only the physical requirements of Mr. E’s occupation to the exclusion of the required interpersonal and intellectual requirements. By reducing Mr. E’s occupation to just the physical demands of whether he was capable of sitting, standing, walking, etc., Lincoln contradicted the clear and unambiguous terms of the LTD Policy in violation of relevant case law and ERISA’s requirement that Lincoln conduct a full, fair and thorough investigation of his claim.
And finally, the appeal noted that the Department of Veterans Affairs (VA) and the Social Security Administration (SSA) both found Mr. E to be totally disabled. In fact, he was given a 100% disability rating by the VA, which is assigned when the impairment is sufficient to render it impossible for the average person to follow a substantially gainful occupation. Further, the SSA awarded Mr. E benefits based on a comprehensive, in-person, medical evaluation by a board certified physician.
Just 1 week after filing his appeal, and after reviewing hundreds of pages of exhibits and medical records, Lincoln overturned its decision to terminate benefits, paid full LTD back benefits and reinstated Mr. E’s LTD benefits. Attorney Symonds continues to represent our client to best ensure that Lincoln will not terminate his benefits again. Feel free to call our disability attorneys for a free consultation.