Standard Overturns Denial of Disability Insurance Benefits
Prior to contacting our office our client had been on disability with Standard due to Ulcerative Colitis and several other serious gastrointestinal conditions for the prior 36 months as Standard had determined she would not be able to perform the material and substantial duties of her prior occupation as an Office Manager. However, with the change in definition to the much maligned “any occupation” standard of disability approaching Standard had begun to compile a strong case against our client culminating in a denial of continued benefits. At that time she contacted our office and spoke with Attorney Stephen Jessup regarding the denial and her rights under her policy.
Standard’s review for continued disability.
Standard has a reputation for completing thorough reviews of disability insurance claims prior to an award or denial of benefits. Our client’s case was no exception to this. Leading up to the denial of benefits Standard had placed our client under two rounds of video surveillance, which documented her spending up to six hours at the gym. After receiving the surveillance reports Standard performed a social media search and found posts by our client about an extensive trip to Europe; information that she had received a certificate as a Certified Personal Trainer; and multiple pictures and posts about her time spent in the gym. Standard felt that this level of activity was not consistent with the information in our client’s medical records or as reported to them in claim forms over the previous three years. Following a review of her file and in light of their background investigations Standard terminated our client’s claim stating she had the ability to perform work at a “Sedentary” demand level.
The Appeal
Needless to say, the information Standard used to terminate our client’s benefit was certainly problematic for our client. However, as Attorney Jessup discovered and argued in our client’s appeal – not everything is as it seems. Upon receipt of the claim file Attorney Jessup reviewed the social media content Standard relied upon and noted that the majority of the posts were dated a year prior to the date of our client’s denial of benefits. Attorney Jessup argued that as the information was not contemporaneous to the date of the denial it was not relevant to the current review and was only representative of a time that Standard had already determined our client to be disabled. Attorney Jessup argued our client’s trip to Europe was a once in a life time opportunity that she took added precaution to ensure airplane seats near the bathroom and hotel accommodations that would make it easier for her to function in the event of a sever flare-up.
In the denial letter Standard indicated that our client’s claim was initially based in part on her diagnosis of obesity. Attorney Jessup argued that in an effort to combat this diagnosis and to attempt to ease the incessant symptoms related to her Ulcerative Colitis our client decided to take control of her health and in turn she took a personal trainer course in an attempt to learn how to lead a healthier lifestyle. It was argued that doing so was tantamount to undergoing physical therapy. Standard failed to take into account that our client’s personal journey to be healthy was in response to her Ulcerative Colitis and desire to better control it. In doing so it did not mean she did not suffer from severe flare ups and restrictions and limitations on account of same. It was also argued that unlike a work place environment, at the gym our client could ensure quick access to restrooms in the event of an emergency or if she was not feeling well to forego activity all together.
Digging deeper into the claim file Attorney Jessup found a peer review report conducted at the request of Standard nearly three years prior to the denial of benefits. In this report Standard’s doctor opined that based on the severity of our client’s condition and her poor response to treatment that our client would be unlikely to return to work in any capacity due to the frequency of her bowel movements. Additional, medical evidence in support and argument that nothing in her medical records indicated a substantial improvement in her condition since Standard’s initial award of benefits was provided in the appeal.
Finally, Attorney Jessup argued that Standard’s assertion that our client was not disabled because she could perform at a Sedentary demand level was an inappropriate standard to determine disability as the policy did not define disability as the inability to perform at a Sedentary demand level. It was clear from the applicable evidence that our client could physically perform many of the requirements of Sedentary demand work such as lifting, carrying and pulling, but her condition is not about her ability to do such activities but rather her ability to maintain reasonable employment on account of her frequent bowel movements and the severe effects of her Ulcerative Colitis.
Upon review and receipt of the appeal, to include all additional medical information, argument and additional information in support of disability Standard overturned its denial of benefits, reinstated are client’s claim and forwarded all past due benefits.
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Q: Do I have to pay back LTD after receiving SSDI?
A: Hello. In most group disability policies there is offset language which states you must pay back any LTD that ... Read More >
Q: Non-taxable benefits have become taxable.
A: I am sorry to hear what you are going through. We have seen you exact fact pattern with tax on ssdi when you w... Read More >
Q: How do I ensure Standard makes a timely decision with regard to my claim?
A: Matthew, we are sorry to hear that you are having difficulty with your claim. While the insurance company does... Read More >
Q: Why can my employer hold my disability check after The Standard sends it to them? Can I file a grievance with them?
A: Lucas, it sounds like your claim for STD benefits is under a policy that is self-funded by your employer. Thus... Read More >
Q: Should I contact you before submitting my application for a private disability benefit?
A: It is in your best interest to contact us as early as possible if you think you are going to need to file a lo... Read More >
Q: Is there any case law in which a state government employee LTD plan decided to drop the 24 month mental health limitation? Has there been any success against a state government and Standard using ADA Title I (employee) and 3 (insurance company) from a discrimination basis?
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