As any chiropractor or anyone who has been to a chiropractor knows – chiropractic medicine is very physically intensive work. The wear and tear a chiropractor can endure over the course of a career often resembles what many patients seek treatment with a chiropractor for. Such was the case with our client, who after 20 years of practice began to succumb to chronic neck pain due to cervical herniations, cervical radiculitis and multiple shoulder problems to include a rotator cuff tear, labral tear, degenerative changes to the AC joint and decreased range of motion. No longer able to meet the physical demands of his occupation as a chiropractor he filed his claim for long term disability benefits with Standard Insurance Company through the policy he had purchased from the Nebraska Chiropractic Physician’s Association (NCPA).
The Denial of Benefits
After many years of faithfully paying his premiums it came as a surprise to our client when Standard notified him that claim was being denied. Concerned by assertions made by Standard as to the nature of his policy and the contents of his denial letter he contacted our Office and spoke with Attorney Stephen Jessup.
In denying our client’s claim for benefits Standard relied on an independent file review conducted by a doctor that never physically examined our client or spoke with any of his treatment providers. Despite years of consistent treatment with medical doctors, chiropractors and objective medical evidence by way of MRIs, Standard’s doctor noted that there was insufficient medical information to support any restrictions and limitations and that our client should be able to return to work full time as a Chiropractor.
Additionally, review of the pertinent information indicated that Standard was erroneously trying to apply ERISA standards to what was an ERISA exempt policy. Attorney Jessup explained how this misapplication could negatively impact our client and how the appeal should be approached in order to protect our client in the event of future litigation.
As Standard was treating our client’s claim as an ERISA based denial of benefits Attorney Jessup remained silent as to the incorrectness of same and moved to quickly secure a complete copy of the claim file from Standard. Upon receipt and review Attorney Jessup discovered that the vocational review conducted by Standard was incomplete and failed to take into account multiple aspects of our client’s occupation as a sole practitioner chiropractor. Furthermore, the review of the medical review evidenced a systematic attempt to downplay our client’s weekly chiropractic treatment and an attempt to require objective medical evidence that does not exist to support our client’s subjective complaints of paint.
After receipt and review of all treatment and medical records Attorney Jessup arranged for additional diagnostic testing, to include a functional capacity examination, in order to better support and bolster the already lengthy history of medical restrictions. With the additional supportive medical information obtained, Attorney Jessup coordinated with our client’s providers to obtain additional supportive letters and forms.
In submitting the appeal Attorney Jessup attacked Standard’s position that the policy was governed by ERISA, as well as undermined both the vocational and medical reviews Standard conducted. Faced with an overwhelming amount of medical evidence and legal argument Standard was left with little choice but to admit its mistake and approve our client’s claim for long term disability benefits.