Our client, Ms. L, formerly worked as a National Account Manager for Delphi Financial Group, the parent company of Reliance Standard Insurance Company. In 2015, a number of medical issues, namely, chronic daily pain, sleep difficulties, fatigue and cognitive and memory impairments forced Ms. L to stop working and submit her claim for long-term disability benefits. In addition to these symptoms her doctors suspected, but later dismissed, lymphoma, on account of abnormal lymph node swelling. After consulting several rheumatologists, Ms. L was diagnosed with fibromyalgia.
Fibromyalgia is a disorder described to result in widespread musculoskeletal pain accompanied by fatigue, sleep, memory and mood issues. Researchers believe that fibromyalgia amplifies painful sensations by affecting the way your brain processes pain signals.
Ms. L’s symptoms became evident in 2015 when her supervisor recommended she take some time off work to take care of herself. It was noted that she was having difficulty managing her pain and was having problems managing her work flow. She was unable to effectively perform the material duties of her occupation, which included, but was not limited to, recommending compensatory strategies, reviewing and negotiating financials, performing new or customer/production implementations, and presenting as well as successfully delivering renewals to customers.
She feared the thought of having to file a disability a claim and leave her rewarding and successful career, however, she knew it was a realistic possibility. Her supervisors were aware of the situation, and despite their current expressions of compassion and understanding, it was only a matter of time before compassion and understanding turned to questions and disappointment concerning her inability to effectively perform her job duties.
Ms. L filed her disability claim, which Reliance Standard approved and paid. After one month, she reported feeling rested and ready to return to work. Unfortunately, her return to work was short-lived. Soon after returning to work Ms. L began experiencing worsening cognitive symptoms triggered by increased stress and she once again was forced to discontinue.
Ms. L notified Reliance Standard of her failed attempt to return to work and that her symptoms had returned. Reliance Standard agreed and reinstated her long-term disability benefits.
Internal Review by a Nurse Consultant Leads to Reliance Standard Terminating the Long-term Disability Claim
To start 2016 Reliance Standard began with conducting a medical review by an internal nurse-consultant. Despite confirming Ms. L’s diagnoses, Reliance Standard’s nurse consultant noted that Ms. L had recently reported improvement in her cognitive function and general symptoms since beginning hormonal therapy. Based on these vague and insignificant statements, the nurse consultant reasoned that Ms. L had made a “full recovery” and was able to return to work. Soon after the nurse consultant documented her findings and Reliance Standard terminated Ms. L’s benefits and communicated its denial in a lengthy letter.
Shortly after receiving her termination letter, a nervous and fearful Ms. L, called Dell & Schaefer and discussed her case with Attorney Cesar Gavidia. Attorney Gavidia saw the gaping holes in Reliance Standard’s denial letter and in the nurse consultant’s medical review, and agreed to prepare and submit Ms. L’s ERISA appeal with the assistance of his appeal team.
The appeal addressed all of Reliance Standard’s short-comings and reasons for denial, with a special focus on the review conducted by the nurse consultant. One of the focal issues was Reliance Standard’s determination that Ms. L had a less than sedentary level of function just one month prior to the nurse consultant’s review of the case.
Approximately sixty days later, and after reviewing the appeal and hundreds of pages of exhibits and medical records, Reliance Standard overturned its decision to terminate the claim and reinstated Ms. L’s long-term disability benefits.