Articles Posted in Short Term Disability

At the O’Ryan Law Firm, we have represented several clients who have become disabled due to the severe symptoms of Scleroderma.

According to the American College of Rheumatology:


Digestive disorders can cause a wide range of symptoms including abdominal pain, fatigue, diarrhea, vomiting, nausea, and weight loss. Inflammatory bowel disease (“IBD”, not to be confused with Irritable Bowel Syndrome, IBS) may be responsible for such symptoms. IBD includes, but is not limited to, Crohn’s disease and ulcerative colitis. When these conditions are not controlled, symptoms may become so frequent and severe that work is not possible.

Testing and Treatment

To assess IBD, the patient should seek treatment with a gastroenterologist. A gastroenterologist (GI) is the appropriate specialist to determine which testing is needed, and which treatment options are available. Available tests include endoscopy/colonoscopy, biopsy, blood tests, stool tests, and small intestine imaging. These tests may need to be repeated on occasion to determine how the disease is progressing.

Treatment options for Crohn’s disease and ulcerative colitis vary patient to patient. Some GI specialists may present surgery as an option, although conservative treatment will be attempted first. Typically, adjustments to diet and medications will be offered first. Types of medication options are aminosalicylates, corticosteroids, immunomodulators, antibiotics, and biologic therapies. A high percentage of Crohn’s disease patients will have surgery, although surgery does not cure Crohn’s – it can only conserve portions of the gastrointestinal tract.

Maintaining Treatment and Recording Gastrointestinal Symptoms

Disabled patients should make sure they maintain treatment with GI specialists, follow their prescribed diet, and follow their doctors’ treatment plans as best as possible. Often, patients will only see their GI specialist on a quarterly basis. Due to the chronic nature of IBD and the possibility that symptoms may wax and wane, it is not possible for patients to see their doctor every time there is a slight change in their condition. Therefore, it is advisable for disabled IBD patients to keep a log of their gastrointestinal symptoms. The log should indicate which days the patient is experiencing gastrointestinal symptoms, how long the symptoms last, and which symptoms are occurring. The patient may also want to note any other important data, such as abdominal pain level (rated on a scale of 1-10), what may have caused the symptoms (such as a stressful situation or a change in diet), and medication taken. For computer and smart phone users, there are options to easily record gastrointestinal symptoms such as GI Buddy App (available for iPhone and Android users). IBD patients should provide copies of their GI logs to treating doctors.
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Many Indiana employees receive group disability insurance coverage through Aetna. Headquartered in Hartford, Connecticut, Aetna is a large disability insurance company that is currently in the Fortune 100. O’Ryan Law Firm has successfully represented many clients whose disability insurance benefits have been unfairly denied or terminated by Aetna.

Short Term Disability Benefits

Aetna’s short term disability coverage pays benefits after a short elimination period (often a week long). Short term disability benefits usually last three to six months. During Aetna’s investigation of the short term disability claim, it is common for Aetna to gather medical records, gather information about the claimant’s job, require statements from treating providers about the claimant’s ability to work and expected duration of disability, and have internal medical consultants review all medical evidence. If the individual is approved for short term disability benefits through the maximum duration of the policy, then they may apply for long term disability benefits.

Long Term Disability Benefits

After an elimination period that is typically the length of the short term disability period, the claimant may apply to Aetna for long term disability benefits. When a claimant receives long term disability insurance through a private employer, their claim is usually governed by the Employee Retirement Income Security Act (“ERISA”).

In addition to information already gathered during the short term disability claim, Aetna will request updated medical records and statements from treating providers, may perform a vocational analysis, and may have internal medical consultants or external medical consultants review the medical evidence. It is very common for long term disability policies to require that the claimant prove disability from their own occupation for the first 24 months of long term disability benefits and then require that the claimant prove disability from any occupation after 24 months of long term disability benefits.

During the long term disability claim, it is more common for Aetna to utilize claim review tactics such as referring the claimant for an Independent Medical Examination (“IME”), contracting private investigators to perform surveillance of the claimant, contracting peer reviewing physicians to review evidence and call the claimant’s doctors, and perform a Transferable Skills Analysis to see if the claimant can return to work in a different job. If a claimant is approved for long term disability benefits, it is likely that Aetna will urge the claimant to apply for Social Security disability benefits. Aetna may even refer the claimant to one of its vendors to represent them in their Social Security disability claim.
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When a person has a medical problem affecting his heart or circulatory system, he may have work restrictions that prevent the ability to continue working. Depending on the severity of the heart condition, working may put a person at risk of suffering a heart attack or other life threatening cardiac event. In these situations, a person with cardiovascular impairments may qualify for short term disability benefits, long term disability benefits, and/or Social Security disability benefits.

Because a heart condition can be life threatening, it is crucial that a person with a cardiovascular problem seek immediate medical attention. When a patient presents with chest pain, palpitations, syncope, or other cardiovascular symptoms, it is common for physicians to order extensive testing. Testing for heart conditions may include echocardiograms (echo), electrocardiogram (ECG), exercise tests, drug-induced stress tests, Holter monitor tests, cardiac catheterization, cardiac computerized tomography (CT) scans, cardiac magnetic resonance imagings (MRI), chest x-rays, and blood tests.

Following the appropriate testing, treatment with a cardiologist is required to document the severity of the heart condition. If a person is required to undergo surgery, then she may have to see a surgeon specializing in heart operations. A cardiologist may only require a patient to follow-up on an annual basis, which means that it is important for the patient to also maintain treatment with her primary care provider and other doctors.

If a person undergoes a cardiovascular event such as a heart attack or surgery, but then is able to return to normal functioning, then he might only be eligible for short term disability benefits. However, if a heart condition requires the person to miss at least three months of work, then he may be eligible for long term disability benefits. To be eligible for Social Security disability benefits, the disability must last or be expected to last 12 months or longer.
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Maintaining or obtaining health insurance coverage is a common problem for those applying for disability benefits. Many Americans receive health insurance coverage through their employer. When a disability forces the employee to stop working, they are at risk of losing their health insurance coverage unless they timely pay the hefty premiums pursuant to the Consolidated Omnibus Budget Reconciliation Act (COBRA). Unfortunately, not having health insurance can be very problematic for those applying for disability benefits.

If the disabled individual is able to afford the premiums for continued health insurance coverage under COBRA, then it is probably in her best interest to pay the monthly premiums and maintain her current health insurance coverage. However, many individuals are unable to afford the monthly premiums without the regular income from a job. When a disabled person cannot make these required payments, they will be forced to find new health insurance coverage or forego health insurance at all.

First of all, applying for disability benefits without health insurance coverage is challenging. Without health insurance coverage, the individual is usually unable to afford the out-of-pocket expenses required for regular medical treatment. The individual may miss out on important testing, medications, and regular examinations. Of course, if the patient is not seeing their doctor, there will be a lack of current medical records to document the patient’s disability. For both long term disability claims and Social Security disability claims, a lack of ongoing medical treatment can make it much more likely that their disability claim will be denied.

Second, the claimant should do everything in his power to obtain health insurance. This includes looking for private health insurance via the federal health insurance marketplace: If the individual cannot afford private health insurance options, they should investigate whether they are eligible for their state’s Medicaid program. For Indiana residents, information about applying for Medicaid can be found at the following website: Even if an Indiana resident is not eligible for Medicaid, they may still be eligible for another state program, such as Care Select, Healthy Indiana Plan, or Hoosier Healthwise. If the individual already receives Social Security disability benefits, then they should eventually be eligible for Medicare, although there is a two year wait to qualify for Medicare.
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The O’Ryan Law Firm has represented numerous clients suffering from fibromyalgia in the disability claims process. Usually, the client contacts our office after their disability claim has been denied and all too often the insurance company or claims administrator has denied the claim because there is “insufficient objective medical evidence” to support the claim. It is improper for your disability insurance company to insist that you produce objective medical evidence to prove that you have fibromyalgia because it is impossible to supply the insurance company with objective evidence that doesn’t exist.

Fibromyalgia is a disease the Seventh Circuit has characterized as “common, but elusive and mysterious.” Sarchet v. Charter, 78 F.3d 305, 306 (7th Cir. 1996). In an evaluating fibromyalgia in the context of a disability claim, the court in Sarchet described the disease as:

Its cause or causes are unknown, there is no cure, and, of greatest importance to disability law, its symptoms are entirely subjective. There are no laboratory tests for the presence or severity of fibromyalgia. The principal symptoms are “pain all over,” fatigue, disturbed sleep, stiffness, and–the only symptom that discriminates between it and other diseases of a rheumatic character–multiple tender spots, more precisely 18 fixed locations on the body (and the rule of thumb is that the patient must have at least 11 of them to be diagnosed as having fibromyalgia) that when pressed firmly cause the patient to flinch.

According to the American College of Rheumatology:

Fibromyalgia is a chronic health problem that causes pain all over the body and other symptoms. Other symptoms that patients most often have are:

• Tenderness to touch or pressure affecting joints and muscles • Fatigue • Sleep problems (waking up unrefreshed)
• Problems with memory or thinking clearly
Some patients also may have:

• Depression or anxiety • Migraine or tension headaches • Digestive problems: irritable bowel syndrome (commonly IBS) or gastroesophageal reflux disease (often referred to as GERD)

• Irritable or overactive bladder • Pelvic pain • Temporomandibular disorder–often called TMJ (a set of symptoms including face or jaw pain, jaw clicking and ringing in the ears)

Symptoms of fibromyalgia and related problems can vary in intensity, and will wax and wane over time. Stress often worsens the symptoms.

The American College of Rheumatology provides the following criteria for evaluating of fibromyalgia:
Criteria Needed for a Fibromyalgia Diagnosis
1. Pain and symptoms over the past week, based on the total of:

Number of painful areas out of 18 parts of the body Plus level of severity of these symptoms:
• Fatigue • Waking unrefreshed • Cognitive (memory or thought) problems Plus number of other general physical symptoms 2. Symptoms lasting at least three months at a similar level 3. No other health problem that would explain the pain and other symptoms.
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Sedgwick Claims Management Services (“CMS”) is a third party claims administrator hired by insurance companies and employee benefit plans to manage disability claims. If your employee benefit plan uses Sedgwick CMS as a claims administrator, then Sedgwick CMS is responsible for deciding whether your disability claim is approved or denied. As well as processing and adjudicating disability claims, Sedgwick holds itself out as providing the following services:

The company specializes in workers’ compensation; disability, FMLA, and other employee absence; managed care; general, automobile, and professional liability; warranty and credit card claims services; fraud and investigation; structured settlements; and Medicare compliance solutions (website last visited August 16, 2014).

Sedgwick CMS is headquartered in Memphis, Tennessee and is one of the largest third party administrators in the nation. Many Indiana employers hire Sedgwick CMS to serve as their claims administrator for employee benefits. Employee benefit plans that currently use or previously used Sedgwick CMS include Eli Lilly & Company, AT&T, Comcast, Walgreens, Franciscan Alliance Inc., SPX Corporation, Ascension Health, Hewlett-Packard, PepsiCo Inc., International Paper, UnitedHealth Group, and many others. If employees of these companies apply for short term or long term disability benefits, Sedgwick CMS is responsible for processing the claims and deciding whether benefits should be paid. As a third party administrator, Sedgwick CMS does not actually pay the disability benefits. Rather, the employee benefit plan or insurance company pays disability benefits if Sedgwick CMS approves the claim. Often, the employee benefit plan has little involvement in the disability claims process, if any.

Like disability insurance companies, Sedgwick initially reviews a disability claim by obtaining medical records, requiring the claimant’s treating physician to complete questionnaires, and having in-house staff (nurses, doctors, vocational analysts, claims analysts) review the claimant’s file. If the claim is denied and the claimant appeals, then Sedgwick’s review of the appeal will likely include the use of contracted record reviewing physicians. If the claim is approved, Sedgwick may call or write to the claimant frequently in efforts to obtain more information. Sedgwick may also require the claimant to undergo an “Independent Medical Examination” or “Functional Capacity Evaluation.”
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The Employee Retirement and Income Security Act (“ERISA”) mandates that insurance companies and claims administrators provide claimants with the specific reasons for the denial or termination of employee benefits and the reasons for the denial must be in writing. See Militello v. Cent. States, Se. and Sw. Areas Pension Fund, 360 F.3d 681, 688 (7th Cir. 2004), cert. denied, 543 U.S. 869 (2004). The Department of Labor has promulgated regulations under ERISA which require certain information to be contained in a denial or termination of benefits letter. Specifically, 29 C.F.R. §2560.503(g) states:

Manner and content of notification of benefit determination.

(1)….The notification shall set forth, in a manner of calculated to be understood by the claimant –

(I) Reference to the specific plan provisions on which the determination is based;

(II) A description of any additional material or information necessary for the claimant to perfect the claim and an explanation of why such material or information is necessary;

These requirements ensure that when a claimant appeals a denial to the plan administrator, he or she will be able to address the determinative issues and have a fair chance to present his case. Halpin v. W.W. Granger, 962 F.2d 685 (7th Cir. 1992). Describing the additional information needed, as required by this section, enables a claimant to gain a better understanding of the inadequacy of his claim and to gain a meaningful review by knowing with what to supplement the record. Wolfe v. J.C. Penney Co., 710 F.2d 388 (7th Cir. 1983).
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Cigna, headquartered in Bloomfield, Connecticut, is a global health services organization and its insurance subsidiaries are major providers of medical, dental, disability, life and accident insurance and related products and services, the majority of which are offered through employers and other groups. CIGNA is one of the top health insurers in North America, with medical plans covering nearly 12 million people. Cigna operates in 30 countries, has approximately 40,000 employees and manages around $54 billion in assets.

CIGNA is the parent company of Life Insurance Company of North America. Life Insurance Company of North America (“LINA”) offers group life, accident, and disability insurance to employers. LINA was formed in 1956 by Insurance Company of North America (INA), a CIGNA predecessor company. LINA provides group disability insurance to many employers across Indiana including Toyota, the University of Notre Dame, State Farm, Sony Electronics, Covance and many others. Employees of these companies are provided short and long term disability benefits if they become unable to work due to injury or illness. LINA is responsible for processing the claims and making monthly benefit payments if the claimant proves that they are disabled and unable to return to their own occupation.

During the claims process, LINA will have a Nurse Case Manager review the medical records to determine whether an individual meets the definition of Disabled under the terms of the policy. If necessary, the Nurse Case Manager will escalate the review to a Cigna Medical Director who is an employee of Cigna. The Medical Director will also review the medical records and reports to determine whether the restrictions and limitations listed by the claimant’s treating physician are supported by the medical records. It is not uncommon for the Nurse Case Manager and Cigna Medical Director to disagree with the treating physician and to find that the claimant is able to return to work despite the medical evidence supporting the claim.
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Spinal injuries or disorders may cause a great deal of pain or limit a person’s movement. There are many causes of spinal conditions, including infections, injuries, degenerative bone changes, spondylitis, scoliosis, and tumors. Some of these disorders can be disabling in nature. Spinal injuries or disorders are relatively common. In fact, spinal conditions and back pain are one of the leading causes of disability.

When a back condition forces someone to miss work, it is necessary to carefully document how the back condition is disabling. First of all, objective testing is required to make a correct diagnosis and reveal the severity of the condition. Objective testing may include x-rays, MRIs, and CT scans, among other tests. One overlooked form of objective evidence is a list of signs observed by the treating physicians. Observable signs may include an abnormal gait when ambulating, pain with movement, and noted areas of the spine which are tender or painful on palpation. Range of motion testing is another type of evidence that is helpful to demonstrate disability. A range of motion test shows the degree to which a person can move each of their joints.

After objective evidence has been used to make a diagnosis, all treatment options must be considered. In most cases, conservative treatment is attempted prior to surgical intervention. Conservative treatment usually means rest, heat or ice therapy, physical therapy or home exercises, pain medications (NSAIDS and/or steroids), injections (nerve blocks and steroids), and non-traditional treatment such as massages, chiropractic adjustments, and acupuncture. If a spinal condition remains severe after conservative treatment and surgery is a possibility, a referral may be made to an orthopedic surgeon or neurosurgeon. Available surgical procedures include laminectomy, discectomy, or a spinal fusion. If surgery is not an option for the patient, then they may be referred to a specialist in pain management.
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