Long Term Disability Benefits Reinstated: After Administrative Appeal filed by Dell & Schaefer, The Standard Overturns Decision To Deny Former Employee of T-Mobile USA
Author: Attorney Alex Palamara
Our client worked as a Retail Sales Leader for T-Mobile USA for a number of years before he was forced to stop working in July of 2010 due to various serious medical conditions. Our client left work due to the restrictions and limitations caused by hepatitis, proteinuria, fatigue, toxic myopathy and dermatomyositis. The dermatomyositis alone left our client with generalized malaise and acute body rashes. At one point his conditions left him in a wheel chair and requiring assistance with bathing, toileting, dressing, transferring and even forced him to be on a feeding tube. Although our client was no longer bed ridden after most of 2011, he still was unable to perform with reasonable continuity the material duties of his own occupation or even any occupation.
Fortunately for our client, his employment at T-Mobile USA provided him with a Long Term Disability Insurance Policy with The Standard Insurance Company should he become disabled and unable to perform the duties of his own occupation or any occupation. Shortly after becoming unable to continue to work due to his various conditions, our client applied for and was approved for Long Term Disability (LTD) benefits by The Standard. These benefits were initially paid from October 2010 through January 5, 2012.
The Standard’s First Denial
By way of a letter dated May 31, 2013, our client was informed by The Standard that his continued benefits were being denied as it believed that he had the functional abilities to perform his prior Light Duty occupation as a Retail Sales Leader for T-Mobile USA. Based on a Physician Consultant’s review, The Standard found that our client was able to resume work back in January of 2012. In further support of its position, The Standard noted the fact that our client was enrolled and taking classes at Arizona State University since the beginning of the 2012 Spring Semester, which began on January 5, 2012. Because The Standard was denying the claim in May of 2013 but found him not disabled since January of 2012, The Standard demanded that over $28,000 be returned as an overpayment for the benefits paid from January 2012 through May 2013.
Shocked and scared due to the amount of money being demanded by The Standard, our client immediately filed an appeal challenging The Standard’s decision. Unfortunately for our client, The Standard upheld most of its earlier decision.
The Standard’s Second Denial
By way of a letter dated November 22, 2013, The Standard informed our client that it was agreeing to pay the LTD claim through June 30, 2013, but was denying the claim thereafter. The Standard noted that according to the policy, as of October 13, 2012 our client had to be disabled from all occupations which he is able to perform which can be expected to earn at least 60% of his indexed predisability earnings within twelve months following his return to work. In support of its position to deny benefits beyond June 30, 2013, The Standard yet again relied upon a Physician Consultant’s review. This reviewer found that due to dermatomyositis our client “was unable to do any level of work consistently until 06/30/2013.” Using the opinion of its reviewer, The Standard found our client capable of performing full time sedentary work as of July 1, 2013.
Claimant Hired Dell & Schaefer
After receiving his second denial letter, our client was relieved to have been awarded additional benefits for the period of January 2012 through June 2013. Unfortunately he realized that he could not yet perform the duties of any occupation and he knew that he was not physically up to the task of filing a second appeal on his own. Nearly 4 months after receiving The Standard’s latest denial letter, our client found Dell & Schaefer and immediately hired us to file the second administrative appeal.
Because the Employee Retirement Income Security Act of 1974 (ERISA) only affords a claimant 180 days to file an administrative appeal to challenge a denial, and because we were not hired until nearly 120 days had past, time was of the essence for Attorney Alexander Palamara to begin Dell & Schaefer’s appeals process.
Appeal filed by Dell & Schaefer
Dell & Schaefer immediately retrieved any and all updated medical records from our client’s treating physicians as well as the claim file from The Standard. A review of all the documents demonstrated that The Standard failed to understand the significance of our client’s medical conditions and the effects these conditions continued to have on his ability to perform the material duties of any occupation, as defined by the policy. The appeal noted that The Standard has continually relied upon “Paper” reviews only to deny his claim, meaning that they have never had a physician examine our client. These paper reviews were conducted despite the fact that the policy governing the claim provides The Standard with the opportunity to have our client “examined at reasonable intervals by specialists of (its) choice.” The Appeal further stressed the consistent opinions of our client’s medical providers and the objective evidence found in the medical records.
With this appeal, we believe that The Standard was left with no reasonable avenue but to reinstate our client’s claim or face a strong lawsuit. Fortunately for our client, the Appeal was successful and The Standard reinstated his claim with benefits being provided from July 1, 2013 forward. Our client remains on claim to this day and he knows that Dell & Schaefer will do whatever it takes to keep our client approved until he is able to return to work or until his policy expires.
If you have been denied disability benefits by The Standard or any other disability insurance provider, please do not hesitate to contact the Attorneys at Dell & Schafer for a free consultation.