Long term disability insurance lawyers in Chicago consult with employees whose long term disability claims have been denied at various stages. The two most common times are when the insurer initially denies the claim and the claimant requires help with the request for review, or after the employee exhausted administrative remedies and the claim is ripe for filing a complaint in court. The difference is the role of the attorney. In one situation, the lawyer helps avoid the worst from happening (e.g., waiting for the resolution of a lawsuit), and in the other situation the lawyer attempts to convince a court the insurer must pay. A reason for denial we see more frequently now is the insurer labeling an objective, supportive test result as not “time concurrent” with the alleged onset of the disability. Absent good logical reason (such as there was a clear worsening of a condition during the time delay), insurers may not discount such evidence. A recent example is in Clark v. CUNA Mutual Long Term Disability Plan, No. 14-cv-412, 2016 U.S. Dist. LEXIS 32945 (Mar. 15, 2016).
In Clark, the plaintiff submitted a claim for long term disability insurance benefits from the CUNA Mutual Long Term Disability Plan following a 2006 injury to his back resulting in disk protrusion, radiculopathy, and sciatica. Clark returned to work, while continuing to experience low back pain radiating down his leg. Clark underwent several courses of physical therapy and surgeries. As the pain worsened, Clark had to stop working. Among other reasons for the denial, the claims reviewer’s medical consultant commented on the lack of updated MRI results. With his appeal, Clark submitted a new MRI that supported the claim, but then the claims reviewer criticized it as not “time concurrent” with when Clark ceased working several months earlier.
Clark sued to recover the benefits under ERISA 502(a). The Court rejected the claim reviewer’s approach, citing binding precedent in the Seventh Circuit. Rejecting evidence on the basis that it post-dates the time the claimant stopped working or when the insurer denied the claim would prevent a claimant from ever being able to successfully appeal an insurer’s adverse benefit determination. See Holmstrom v. Metro. Life Ins. Co., 615 F.3d 758, 776 (7th Cir. 2010). For a description of the requirements on claims reviewers and insurers when reviewing claims for group long term disability insurance under ERISA, see 29 C.F.R. 2560.503-1. Insurers have given similarly failing rationales to disregard evidence post-dating the benefit termination date in other cases. See Barbu v. Life Ins. Co. of N. Am., 35 F. Supp. 3d 274 (E.D.N.Y. 2014). The court thus granted Clark summary judgment and remanded the matter for further consideration.
While a good attorney can save your claim in court if an insurer disregards some of your evidence, the preferred course of action is to not let your case get to court. Immediately after receiving a denial of a long term disability claim, discuss your options with an experienced ERISA long term disability insurance lawyer, rather than immediately performing the appeal yourself.