Standard Overturns Decision to Deny Disabled Project Manager Long-term Disability Insurance Benefits After First Appeal
Author: Attorney Cesar Gavidia
Terry had worked as a project manager for a large national health group earning over $85,000 annually, until type 2 diabetes left him disabled and suffering from peripheral diabetic neuropathy, severe chronic pain, fatigue and depression.
In addition to health insurance and other employee benefits his employer provided long-term disability insurance through Standard Insurance Company, based out of Portland, Oregon.
In 2010, Terry was forced to file a long-term disability claim with Standard Insurance Company (“Standard”) informing him that due to his debilitating disease he was no longer able to perform with reasonable continuity the Material Duties of his Own Occupation.
Soon after filing his disability claim Standard informed Terry that his claim was approved, which came as no surprise to him given the extent of his health issues.
Standard Terminates Long-term Disability Claim After 24 Months Claiming that the Disability was Due, In Part, to a Mental Disorder
The primary cause of Terry’s disability was and always had been type 2 diabetes and peripheral neuropathy. His pain had become so severe and had caused him to give up a successful career it was no surprise that Terry also began suffering acute depression symptoms related to the worsening of his physical state. Terry had also been diagnosed with bipolar disorder and anxiety, which complicated matters.
After paying his long-term disability claim for 24 months Standard informed Terry that it would no longer pay benefits beyond the 24 month period on account of his disability being “caused or contributed” to by a mental disorder. It was true that Terry suffered from mental illness, however, he had not claimed that depression nor any other mental illness was the sole or primary cause of his disability. Notwithstanding, Standard proceeded with the termination of Terry’s long-term disability claim on the grounds that his disability was caused or contributed to by a mental disorder. As part of their basis for denial, Standard cited the opinion of a hired medical consultant. That medical consultant attempted to minimize the extent of Terry’s physical disabilities while accentuating his mental disorders.
Following Submission of ERISA Administrative Appeal by Attorney Cesar Gavidia Standard Overturns Decision to Limit Long-term Disability Claim to 24 months
In response to Standard’s decision to terminate Terry’s long-term disability claim after 24 months, Attorney Cesar Gavidia and his appeal team began compiling the necessary evidence and implementing their plan of attack. Terry’s appeal served not only to detail and uncover all of the flaws and errors in Standard’s decision, but also to ensure a strong administrative record in the event that Standard decided to uphold its decision and the case were to proceed to federal court litigation.
Fortunately, a more expeditious and just result occurred. After receiving the appeal submitted by Attorney Gavidia and his appeal team, Standard overturned its decision and began paying benefits specifically for Terry’s type 2 diabetes, peripheral diabetic neuropathy and other physical complications.
Terry continues to receive monthly long-term disability insurance benefits from Standard while Attorney Gavidia continues to assist him with the ongoing and seemingly never-ending requests for health and status updates from Terry and his attending physicians.