Under ERISA, one of the rights you have as a part of your disability benefits claim is the right to a “full and fair review” by the insurance company.

In providing a “full and fair review” the insurance company cannot cut corners or rely on generalizations to evaluate your claim. Instead, the insurance company has to look at you, as a person, and consider your illness and conditions and how they affect your ability to work.

This issue was recently litigated by our office in Terry Lewis v. Liberty Life Assurance Co. of Boston, U.S. District Court, WDKY, Civil Action No. 3:12-cv-00215-H. Our client Terry Lewis had been denied Waiver of Premium benefit for a life insurance policy. For many workers, a life insurance policy is one of the largest assets they have to pass on to their family. For some people this can be as important as their claim for long-term disability benefits.

In the Lewis case, we won our client’s long-term disability benefits appeal. While her long-term disability benefits were reinstated, she was denied waiver of premium benefits. The reason for the different evaluations of her claim was that her long-term disability benefits were based upon an inability to do her own job, and the waiver of premium benefits were based on an inability to do any job.

We asked the Court to reverse the insurance company’s decision to deny the waiver of premium benefits because the insurance company, Liberty, did not provide a “full and fair review” of the claim.

In our case, the medical evidence showed that our client had several significant medical conditions. These included diabetes, degenerative disc disease and arthritis, among others. These conditions affected her ability to work, and not only to walk, stand, lift and carry, but to show up to work regularly, and to stay on task while at work.

Liberty was presented with evidence on appeal from our client’s doctor, stating that he had personally examined Ms. Lewis, had treated her for years, and that the combination of her conditions was so severe that she could not work. Liberty ignored his opinion.

Instead, Liberty hired MES Solutions, Inc., a third-party vendor, to find a physician to review the file and provide another opinion. That physician, Dr. Greg Marella, agreed that Ms. Lewis had all of these conditions, but decided that her symptoms were not severe enough because “millions of people” have diabetes or chronic pain and are able to work. Although Liberty had the right to have Ms. Lewis examined to see how severe her symptoms were, it decided not to have such an exam performed.

As we argued to the Court, Liberty’s actions were not a “full and fair review” under Section 503 of ERISA,  which requires plans to set up procedures to provide a full and fair review of denied benefit claims.  Liberty agreed that our client Ms. Lewis had all of the conditions which would render her disabled, but decided that her symptoms were not severe enough to disable her, based on the physician’s generalizations.

While an insurance company can, in some situations, rely on a physician’s paper review of your medical records, it can be inappropriate for the insurance company to rely on a paper review of your file when the question is really how severe your symptoms are, and whether the statements you make regarding your symptoms are credible.

The Judge agreed that Liberty had not provided a “full and fair review” of our client’s claim. As the Judge noted, the report from Liberty’s doctor implied that our client Terry Lewis was either faking her illness, or being outright deceitful about her conditions. The Court noted that it could not “single out objective medical evidence on which Liberty relies in its denial of benefits that does not involve some material element of a credibility determination.”

The Court concluded that Liberty’s review was not a “full and fair review.”  While the Court did not reinstate the benefit, it sent the case back for an investigation that complied with ERISA. While we believe the Court should have reinstated the benefit, we were pleased that the Court recognized that our client’s rights were violated and that this wrong needed to be addressed.

A claim for ERISA benefits, whether long-term disability benefits or waiver of premium benefits, can present a lot of questions:

• How does my policy define disability?
• Do I have to be disabled from my job OR any job?
• Did a doctor review my file and, if he did, what did he do?
• Did the insurance company provide a “full and fair review” of my claim, or should they have done something different?

These can be very difficult questions. At McDonald & McDonald we work with you to find the answers. We help individuals who have been denied long-term disability benefits, and other benefits provided under ERISA. We work with people to appeal the denials of their benefit claims and to litigate claims when their administrative appeals have been exhausted.

As in Terry Lewis’ case, it is most beneficial if we get involved in preparing your appeal when your claim for benefits is first denied. By having an attorney included early on, you have a better opportunity to present quality evidence for your appeal, and to lay the groundwork for future litigation, if necessary.

 

Questions about your long term disability insurance claim?

 Call (877)-428-9806 today to discuss how we can help you obtain a “full and fair review” of your long-term disability benefits or waiver of premium claim.