Senior Merchant of American Fashion Retailer Giant gets LTD Claim Approved After Appeal to Reliance Standard
Author: Attorney Alex Palamara
A Senior Merchant for Express, Inc., was forced to stop working after suffering a traumatic brain injury due to a motor vehicle accident which occurred in December 2015. This accident literally caused her life to come to a crashing halt. She previously worked for Express for 6 years. She loved her job, made a great living, and thrived in the fast paced work environment of the fashion industry. Unfortunately for her, a new reality kicked in after the car accident which lead to daily headaches, daily pain, sleep issues, fatigue, cognitive issues, etc. Her issues led her to be unable to continue working at her occupation.
Luckily for her, her employment at Express, Inc. provided her with Long Term Disability Insurance Coverage under a policy with Reliance Standard. Shortly after the car accident, she applied for benefits and benefits were initially approved and paid from March 2016 until September 2016. Additional benefits beyond September 2016 were denied by way of a December 1, 2016 denial letter. In support of Reliance Standard’s decision to deny continued LTD benefits, the insurance company stated that a review of the recent medical records showed that there was “now no significant findings regarding your mental and physical status that would preclude you from preforming the material and substantial duties of your occupation.” Unfortunately, the former Senior Merchant knew that she could not work and knew Reliance Standard’s review was wrong. Dismayed and confused as to why her claim was denied, she decided to find assistance with her claim and found Attorney Alexander Palamara of the Dell & Schaefer law firm.
Appeal by Attorney Palamara
After reviewing the denial letter and speaking with the former Senior Merchant, it was clear to Attorney Palamara that Reliance Standard’s decision was not only wrong, but arbitrary and capricious. The claim file from Reliance Standard was ordered, as well as the updated records from our now client’s treating physicians. Furthermore, a neurological Independent Medical Evaluation was arranged so that our appeal could include support outside of the great support of her treating physicians.
After compiling and reviewing all the necessary information, it was clearer than ever that benefits had to be reapproved. An appeal was drafted and timely filed. The appeal focused on the objective medical evidence which supported the existence of our client’s medical conditions. It also included statements of support from her treating physicians that stated why they supported their patient’s claim. For instance, one treating doctor stated that “As a result of the accident, my patient demonstrates full physical and emotional difficulties and limitations that would more likely than not prevent her from performing the material duties of any occupation. This is due to a lack of concentration, physical discomfort, and consistently poor sleep all of which contribute to performance limitations.” Similarly, the doctor who performed the neurological Independent Medical Evaluation stated “the patient does not have work capacity on a full time consistent basis as of 09/29/2016 and going forward because of her post concussive symptomatology of headaches, memory issues, overload, sleep, fatigue issues, neck and shoulder problems, balance issues, anxiety, mood and temperament issues, reading difficulty, and sensitivity to light and noise.” He continued that her “prognosis is uncertain for now, but hopefully with current treatment and perhaps new therapies, the claimant may completely recover over time. It should be noted she is slowly improving over time.”
In addition to summarizing the great support of the objective evidence and treating physicians, Attorney Palamara also showed the insurance company that the cherry picked statements from our client’s medical records that it was attempting to rely upon to deny the claim were in fact supportive of her claim when one actually reviews the full medical document. Attorney Palamara also heavily critiqued the reviews that were conducted.
Less than 5 weeks after the appeal was filed, our client’s claim was reapproved by way of a letter of September 2017. Thankfully, Reliance Standard quickly saw that its decision was wrong and improper, and it immediately reinstated our client’s claim. Of course our client is ecstatic to be back on claim and is now able to again focus on her health. She knows that the fight will continue, but she also knows that Dell and Schaefer will do whatever it takes to keep her on claim until she is ready and able to return to work.
If you have had a similar situation and Reliance Standard (or any disability insurance company) has denied your claim, please do not hesitate to contact Attorney Alexander Palamara at Dell & Schaefer for a free consultation.