From 1997 to 2003, Bobby Nelson worked as a buyer for AMCOM until he became completely and totally disabled due to the displacement of a lumbar intervertebral disc in his lower back. Mr. Nelson’s last day of working full-time at AMCOM was December 26, 2003. Three days later, he had posterior and anterior fusion of the L4 and L5 vertebrae performed on his lumbar spine. The surgeon also placed bilateral pedicle screws and a disc fixator device in Mr. Nelson’s lumbar spine to maintain the integrity of the lumbar vertebrae. However, Mr. Nelson experienced chronic and continuing lower back and leg pain following surgery.
That prompted Mr. Nelson to file a claim with Lincoln National life Insurance Company (Lincoln) - formerly doing business as Jefferson Pilot Financial Insurance Company – for disability benefit payments because he was not able to work with reasonable continuity due to the chronic disabling condition in his lower back.
Disabling conditions related to the back and spine are common causes for people filing for long-term disability benefits from their insurance company – as is the case with Mr. Nelson. Sometimes long-term disability insurance companies challenge claims resulting from back problems because of insufficient medical documentation provided by the treating physician. Sometimes the exact cause of a person’s back problems isn’t easily determined.
With that being the case, let’s see how Lincoln handled Mr. Nelson’s claim for long-term disability benefit payments.
Lincoln initially approved Mr. Nelson’s claim for long-term disability benefit payments from January 5, 2004 to September 5, 2005. Lincoln later denied Mr. Nelson any further benefit payments, “by a finding that the medical documentation no longer supported restrictions or limitations which would preclude him from performing the main duties of [his] own occupation as a purchasing agent.” Naturally, Mr. Nelson appealed Lincoln’s decision to terminate his long-term disability benefit payments via a letter dated January 19, 2007. Ten days later, Genette Albertsen DIA, Disability Appeals Specialist for Jefferson Pilot Financial Insurance Company (Lincoln) acknowledged receipt of Mr. Nelson’s written appeal.
Ms. Albertsen notified Mr. Nelson on May 16, 2007 that the Appeals Council upheld the original decision to terminate his long-term disability benefit payments as of September 5, 2005. She further advised Mr. Nelson that his administrative remedies are at the point of exhaustion and he could pursue legal action against Lincoln under ERISA.
Therefore, Mr. Nelson and his disability lawyer filed a civil complaint in United States District Court for the Western District of Missouri in the Southern Division against Lincoln for terminating his long-term disability benefit payments as of September 5, 2005.
Mr. Nelson alleges that “[Lincoln’s] determination denying [his] claim for benefits was unreasonable, arbitrary and capricious, and contrary to the terms of the plan.” Mr. Nelson contends in his complaint that as of September 5, 2005, he was still completely and totally disabled as result of the chronic back and leg pain in his back. Nevertheless, according to Mr. Nelson, Lincoln refused to make benefit payments to him after September 5, 2005.
For his relief, Mr. Nelson is seeking judgment in his favor and asking the court to compel Lincoln to:
- consider additional indication of ongoing disability
- pay him long-term disability benefits retroactive to September 5, 2005 to the date of judgment
- pay him long-term disability benefits into the future
- pay prejudgment interest
- all costs associated with this litigation