Surveillance Video and Independent Medical Examination (IME) Leads to Disability Insurer Terminating Disability Claim After Paying Partially Disabled Insurance Agents Claim For 21 Years

Our client, Richard, was working as an insurance agent when he began experiencing pain in his lower back. After consulting a physician and undergoing a CT scan and MRI, a ruptured lumbosacral disk was discovered. As an insurance agent, Richard understood the importance of maintaining disability insurance and he had personally purchased an individual disability insurance policy, insuring him for both total and partial disability from his occupation as an insurance agent.

Following the diagnosis of his ruptured disk, Richard’s physicians recommended surgical laminectomy and discectomy to repair the lumbosacral space. Ten days following his surgery Richard began experiencing severe pain in his low back and right side. Richard presented to the ER, where they treated him conservatively and sent him home. Richard’s pain persisted so he returned to the hospital where an MRI was performed, which revealed to be mostly normal. He was once again treated conservatively and sent home with instructions to remain on bed rest. Richard continued to suffer severe pain to the point that he returned to the Emergency Room and a repeat MRI showed definite discitis and destructive inflammation.

With treatment, therapy, and medication, Richard’s inflammation soon lessened, but, his pain persisted. Richard eventually returned to work, but his chronic back pain only allowed him to work part-time. Despite his best efforts to generate income similar to the income he was generating prior to his surgery, Richard’s sales and revenue suffered. It was simply impossible to generate his pre-disability income working only ten hours per week, when he had previously worked 50+.

Richard contacted his disability insurer and informed them that would need to file a claim under his policy. Richard was not surprised when his disability insurer, after reviewing his claim, determined that he was indeed unable to spend as much time at his occupation as he did before his disability started, and that he had at least a 20% loss of income, thus qualifying him to receive partial disability benefits.

For the next 21 years Richard’s long-term disability in surer paid his partial disability claim. Although Richard left his employer soon after his disability claim was approved to run own insurance agency, where he could manage his own hours and accommodate his medical issues, his disability insurance company, paid faithfully for the entire period.

Around year 21 of the disability claim, the claim transferred to a new claim representative. The new claim representative requested updated medical records, which they had reviewed by their internal medical consultant. Following the medical consultants review, they determined that they should obtain surveillance video of Richard, and request an Independent Medical Examination (IME) by a physician outside of the disability insurance company. The IME examined Richard and reviewed the surveillance video provided by long-term disability insurance company, which showed Richard getting in and out of cars, engaging in conversations, running errands, walking, rolling a suitcase, and using a cane.

The IME concluded, based on a brief examination of Richard’s lower back, but without reviewing any recent MRI, that Richard was capable of working full-time as an insurance agent and in any sedentary occupation. In reaching his opinion, the IME never discussed Richard’s occupation with him, much less his specific occupational duties or the physical, intellectual and cognitive demands of working in insurance sales and operating your own agency. No mention of any of Richard’s occupational duties appeared in the IME’s report. Without knowing anything about the actual physical demands of his job in insurance sales, the IME opined that Richard was capable of not only performing the sedentary duties of an insurance agent, but also those of a light duty occupation. At the conclusion of his IME he acknowledged that he based his opinion without an updated MRI, and stated that he did not have enough information to say whether or not additional treatment including surgery would be of benefit to Richard.
The long-term disability insurance company decided to terminate Richard’s claim, and its decision essentially mirrored the opinion of its IME. It claimed that Richard was not only capable of the sedentary duties of an insurance agent, but also those of a light duty occupation.

For a short time, Richard attempted to resolve the matter directly with his disability insurance carrier. He wrote letters, provided more medical records and spoke numerous times with the claim representative. However, none of his strategies and efforts proved to be fruitful, and he contacted Dell & Schaefer, hiring Attorney Cesar Gavidia to represent him.

Richard and his long-term disability insurance carrier, with their attorneys, agreed to participate in a pre-suit mediation, where Attorney Gavidia and the disability insurance company’s in-house general counsel gave compelling and well-prepared presentations and arguments. The evidence, including Richard’s recent medical treatments, MRI’s, and even the surveillance videos were discussed and argued over. After many hours of negotiation and presenting evidence and arguments, the parties reached a confidential monetary settlement to their mutual satisfaction.

Questions About Hiring Us

Do you work in my state?

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.

What are your fees?

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.

Do I have to come to your office to work with your law firm?

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, 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.

How can I contact you?

When you call us during normal business hours you will immediately speak with a disability attorney. We can be reached at 800-682-8331 or by email. Lawyer and staff must return all client calls same day. Client emails are usually replied to within the same business day and seem to be the preferred and most efficient method of communication for most clients.

Dell & Schaefer Client Reviews   *****

Jo Ann M.

I contacted Stephen Jessup when I was appealing the decision to terminate my LTD benefits. I did not proceed with his services at that time but because of his encouragement, kindness and expert guidance, I called back after I lost my appeal. Happily, he was able to obtain a settlement for me which was a Godsend and helped me get back on track financially. I would not have given a thought to pursuing any course of action if it weren’t for Stephen’s advice and guidance. I am so grateful for what he did for me. It was a life changer. Thank you.

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