Our client, a former Senior Project Manager for a national corporation, was receiving long term disability benefits from Reliance Standard due to debilitating chronic pain stemming from a multitude of lumbar and cervical spine disorders. Reliance Standard initially approved his claim for short term disability benefits and without issue approved his claim for long term disability benefits once the period of short term disability had expired. Our client had very little difficulty dealing with Reliance Standard and expected that his claim would continue to be paid. However, as is too often the case, our client was unfortunately mistaken.
As his claim transitioned from the “own occupation” to “any occupation” period of disability he began to experience problems with Reliance Standard. Nearly eight months prior to the transition date from the own to any occupation disability period, Reliance Standard advised our client in March of 2017 that it had determined he would no longer be disabled from performing sedentary and/or light duty work as of ?November 2017, and in turn his claim was being terminated. It was then that he contacted Attorneys Dell & Schaefer and spoke with Attorney Stephen Jessup.
The Administrative Appeal
In reviewing Reliance Standard’s denial letter and our client’s claim file it became very clear to Attorney Jessup that Reliance Standard’s logic in terminating our client’s claim was wrong on two accounts. First, how could Reliance Standard render any opinion as to the status of our client’s medical condition eight months into the future, and second, given that his occupation was sedentary in nature and that there had been no substantive change in his medical condition it made no logical sense that he would all of a sudden be able to return to the workforce in a similar physical capacity. To drive home the fact our client would not physically be able to work, during the course of drafting the appeal, Attorney Jessup had our client undergo a Functional Capacity Evaluation (FCE) to verify his physical ability for work as set forth by the Department of Labor. The FCE confirmed that our client would not have the physical ability to sustain light or sedentary work demands on a full time basis.
Creating an additional layer of difficulty in re-securing our client’s disability benefit was the fact that Reliance Standard was not only arguing a lack of medical evidence to support ongoing physical restrictions and limitations, but they were also posturing to assert plan language, which despite our client’s physical disabling conditions, could limit payment on his claim to two years. Specifically, in our client’s policy there was language very common to Reliance Standard disability insurance policies relating to mental health conditions:
Mental or Nervous Disorders: Monthly Benefits for Total Disability caused by or contributed by mental or nervous disorders will not be payable beyond an aggregate lifetime maximum of twenty-four (24) months…
Like many people suffering from chronic pain conditions there is an element of depression and anxiety that arises secondary to the physical medical conditions. As Reliance Standard’s policy had a discretionary clause, which allows the company to interpret its policy terms as it sees fit, Reliance Standard was poised to make an argument that despite our client’s physical conditions that his secondary depression/anxiety “contributed” to his disability and thus his claim could be limited to 24 months.
Although Attorney Jessup had no choice but to acknowledge the mental health diagnoses in our clients claim, he argued and proved, that the secondary mental health conditions did not contribute to our client’s disability and that but for his multiple back and neck conditions he would be able to work.
During the course of the appeal, faced with strong evidence in support of disability, Reliance Standard made one final attempt to uphold its denial of our client’s claim and sent him for an Independent Medical Examination (IME) with a doctor specializing in Occupational and Environmental Medicine. In advance of the IME, Attorney Jessup researched the doctor hired to perform the exam and consulted with our client as to what he could expect during the course of the exam. Based on all the information collected to date, Attorney Jessup was confident that the IME doctor would confirm our client’s verifiable physical restrictions and limitations that were preventing him from working on a full time basis.
Following the IME, as requested by Attorney Jessup, Reliance Standard provided a copy of the IME report for review and requested that any comment regarding same be made prior to Reliance Standard completing its review of the appeal. Attorney Jessup noted that the IME report strongly supported disability and wrote Reliance Standard a detailed letter highlighting the portions of the IME report that made it clear our client should continue to receive benefits.
Within a week of being provided the IME report Attorney Jessup received notice from Reliance Standard that it was reinstating our client’s claim and issuing all past due benefits. Best of all for our client, due to the advanced denial of benefits and the fact Attorney Jessup was able to prepare and submit the appeal well in advance of the 180 day deadline, our client never missed a benefit check period while waiting for Reliance Standard’s decision on his appeal.
Attorney Jessup continues to represent our client to best ensure that Reliance Standard continues to honor its duty to issue disability benefits to our client. Feel free to contact our office to speak with one of our disability attorneys regarding any questions you may have related to a disability insurance matter.