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Standard Insurance Company’s denial of long-term disability benefits to an attorney is reversed by federal court

The case we are going to discuss here highlights one of the ways an insurance company attempts to justify discontinuance of benefits after they have begun paying them.

George Nevitt, a practicing attorney fell down a flight of stairs on June 19, 2001. His injuries were so severe, that The Standard Insurance Company (Standard), the company that provided his company’s employee welfare benefit plan, initially approved Nevitt’s claim for disability benefits. In April 2007, Standard terminated Nevitt’s coverage claiming that he no longer qualified because of the mental disorder limitation of the plan.

After Nevitt exhausted all of his administrative remedies he filed suit before the United States District Court for the Northern District of Georgia, Atlanta Division, requesting summary judgment. Standard responded by moving for summary judgment on their behalf. Nevitt responded by filing a cross motion for summary judgment, to which Standard responded by filing an additional motion for summary judgment. Nevitt then moved to strike Standard’s additional motion.

Let’s look at the background presented by the administrative record. After his fall, in June of 2001, Nevitt began to experience frequent migraine headaches, pain in his neck and both arms. His cognitive abilities were also impaired. In August, he saw his primary care physician, a neurologist and a physical therapist. He was forced to cut back the number of hours he worked and finally underwent an MRI in September. The MRI revealed that he had herniations on both the C-4 – C-5 and C-6 – C-7 discs as well as a deformation of his spinal cord. Additional damage was also apparent in the MRI.

On November 15, 2001, Nevitt filed a claim for partial disability benefits. He had not been with the legal firm for a full year yet, so Standard ensured that Nevitt did not have a pre-existing condition. Standard had an internal medicine consultant review his medical records. This doctor noted that no pre-existing condition was found and that Nevitt’s condition should gradually improve over time.

When Nevitt’s condition did not improve, his neurologist recommended that he consult a neurosurgeon. He did this in May of 2002. The neurosurgeon suggested that he needed surgery to repair the herniations and spondylitic spurring shown on the MRI. Nevitt was reluctant to undergo the surgery, so the neurosurgeon referred him to a board certified pain management and rehabilitation specialist.

In December of 2003, Nevitt stopped working entirely. An independent medical examiner checked him for his workman’s comp claim. The doctor that conducted the exam reported that he could return back to work if the duties of his job were modified. Nevitt went back to his neurosurgeon who again recommended surgery, and also referred Nevitt to a neuropsychologist who diagnosed him with post-concussive injuries, concluding that Nevitt’s cognitive impairment affected his ability to practice law. He noted that Nevitt was emotionally distressed which was affecting his cognitive abilities, and as a result, he recommended pharmacological treatment for depression.

Nine months later in August 2004, Standard ordered an independent medical examination. This doctor concluded that Nevitt had no neuropsychological issues that would limit his ability to work. However, his attending physician disagreed and continued to restrict him from working.

Another year passed. In August 2005, Standard asked a neurologist to review Nevitt’s records. This neurologist concluded that Nevitt was not disabled from practicing law and recommended follow-up treatment for Nevitt’s migraines. At the same time, Standard asked a psychiatrist to review Nevitt’s records. The psychiatrist concluded that he had suffered from major depression at times but he could return to work with continuing emotional support. His treating physician disagreed with this diagnosis, and continued to restrict him from returning to work.

In October 2006, Standard ordered an independent medical exam. This neurologist, after seeing Nevitt, concluded that Nevitt’s complaints were out of proportion to his injury and there was no reason why he could not perform a sedentary desk job without any restrictions.

Standard terminated Nevitt’s long-term disability benefits in April 2007. They stated that his benefits were limited to 24 months because anxiety and depression contributed to his disability. He appealed on October 12, 2007, citing his cervical pain, migraine headaches, and brain injury, which were independently disabling and were not subject to the mental disorder limitation. He provided affidavits from his attending physicians, a detailed account of his fall, a functional capacity evaluation and job simulation test as evidence of his disability not being related to a mental condition. The same claims specialist who had determined that he no longer qualified for long-term disability reviewed the additional material and upheld the termination.

The file was sent to Standard’s Administrative Review Unit for an independent review.  Nevitt submitted additional documentation. One report from a neurologist stated that his migraines could be expected to cause him to miss 5 to 7 days of work every month. A second report from a vocational consultant stated that Nevitt was no longer able to practice law because of his limitations. Standard also submitted a neurologist’s report that disagreed, claiming that the migraine should only impair Nevitt for one or two days per occurrence, concluding he could not see how this would disable him from practicing law.

The Administrative Review Unit upheld Standard’s termination of benefits. They gave Nevitt copies of the medical records that were used to make its determination. In response, Nevitt underwent additional tests to address the concerns that Standard’s consulting physicians had expressed. The results of these tests were sent to the claims specialist for consideration. The specialist stated that the tests relayed no new information and the original decision to terminate was upheld.

In order to sort this matter out, the Court looked at several things. First, the Court had to evaluate the reasonableness of Standard’s determination in the light of the material recorded in the administrative record. To do this the Court had to determine whether the Court agreed with the claim administrator’s benefits denial decision.

The Court looked at the policy language, asking what had Standard promised in the policy? First, the policy stated that it covered disability which resulted from physical disease, injury, pregnancy, or mental disorder if the policyholder was unable to work within their “own occupation.” The policy stated that long-term benefits were limited to 24 months for “each period of continuous disability caused or contributed to by a mental disorder.” Included in mental disorders were things such as “depression or depressive disorders” and “anxiety and anxiety disorders.”

Nevitt argued that his condition did not fall under the clause for mental disorder because he was totally disabled apart from any mental problems that he might have. The Court agreed. When the Court reviewed the administrative record used at the time of the decision to terminate Nevitt’s long-term disability policy, the Court reached a different decision. They determined that the administrative record demonstrated at least three conditions, other than a mental disorder, that contributed to Nevitt’s disability. The medical records substantiated the continued probability of Nevitt’s missing work for at least 5 to 7 days per month, which is unacceptable in the practice of law.

Nevitt’s motion for summary judgment was granted on December 3, 2009. Standard was ordered to reinstate his long-term disability benefits.

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There are 3 comments

  • I had an FCE in Jan. and, according to Labor Dept. Standards, my evaluators rated me at sedimentary 10 lb. max. I sent my knee should back and FCE to the Standard LTD insurance. I’m still waiting for my appeal. I’m thinking they may say I can sit in a chair greeting customers at Wall Mart to get out of paying me $238 / month plus the $4500 / year into my retirement savings 403B at TIAA Cref. So I’m still waiting.

    Thanks for your time.

    Gordon McRaeFeb 19, 2013  #3

  • Gordon,

    There are multiple things we would do in your case, but we would need to see your definition of disability in your policy, review your denial letter, review your medical records, and review the claim file in order to provide any advice. We provide a free consultation to review your claim. You can also gain some information about ERISA appeals by watching the Appeal videos on our website.

    Gregory DellJan 5, 2013  #2

  • I’ve been disabled since June 2010, I’m still on workers comp in Vermont. I see you’ve dealt with the Standard Long Term Disability Insurance Corp. before.

    They say I’m qualified to get my 70% benefit until Dec 2013. However they are not providing me the waiver of life insurance premium now. In Aug 2012 they sent a letter informing me that although I could not lift more than 20 lb. due to my lower back work I injury, ruptured L4 L5 with disc compression at L2 & L3, their vocation specialist says I can do a job requiring I lift 10 lb. over my head and stand for at least 1 hour at a time and listed 3 jobs I could do. Of course none are available in Saint Albans Vermont. Also, I have a right knee injury and right shoulder injury with bone on bone issues with pain and swelling. I’ve been told I have limited range of motion on both joints and I’m looking at joint replacements at some future point. I’ve had XRays and 2 MRIs on my lower back. I also have a right knee injury and right shoulder XRays I’m appealing with the Standard Long Term Disability Insurance Corp. decisions.

    Do you have any advice?

    Gordon McRaeJan 4, 2013  #1

FAQ

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We represent Standard clients nationwide and we encourage you to contact us for a FREE immediate phone consultation with one of our experienced disability insurance attorneys.

Can you help with a Standard disability insurance policy?

Our disability insurance lawyers help policy holders seeking short or long term disability insurance benefits from Standard. We have helped thousands of disability insurance claimants nationwide with monthly disability benefits. With more than 40 years of disability insurance experience we have helped individuals in almost every occupation and we are familiar with the disability income policies offered by Standard.

How do you help Standard claimants?

Our lawyers help individuals that have either purchased a Standard long term disability insurance policy from an insurance company or obtained short or long term disability insurance coverage as a benefit from their employer.

Our experienced lawyers can assist with Standard:

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Yes. We are a national disability insurance law firm that is available to represent you regardless of where you live in the United States. We have partner lawyers in every state and we have filed lawsuits in most federal courts nationwide. Our disability lawyers represent disability claimants at all stages of a claim for disability insurance benefits. There is nothing that our lawyers have not seen in the disability insurance world.

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Since we represent disability insurance claimants at different stages of a disability insurance claim we offer a variety of different fee options. We understand that claimants living on disability insurance benefits have a limited source of income; therefore we always try to work with the claimant to make our attorney fees as affordable as possible.

The three available fee options are a contingency fee agreement (no attorney fee or cost unless we make a recovery), hourly fee or fixed flat rate.

In every case we provide each client with a written fee agreement detailing the terms and conditions. We always offer a free initial phone consultation and we appreciate the opportunity to work with you in obtaining payment of your disability insurance benefits.

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No. For purposes of efficiency and to reduce expenses for our clients we have found that 99% of our clients prefer to communicate via telephone, e-mail, fax, GoToMeeting.com sessions, or Skype. If you prefer an initial in-person meeting please let us know. A disability company will never require you to come to their office and similarly we are set up so that we handle your entire claim without the need for you to come to our office.

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