O’Ryan Law Firm, on behalf of our client, recently settled an accidental death insurance claim filed against Cigna, and the client’s employer, after Cigna refused to pay her accidental death insurance claim upon the accidental death of her husband.  The insurance coverage was purchased through her employer and insured by Cigna.  Shortly after she was hired, our client Ms. Y enrolled in accidental death insurance coverage for her husband through her employer and paid the premiums for the coverage through payroll deductions.

Unfortunately, several weeks after she started her new position, Ms. Y’s husband was killed in a traffic accident when he was struck by multiple motor vehicles while attempting to cross the street.  After her husband’s death, Ms. Y completed and submitted all paperwork provided to her by her employer in order to submit a claim to Cigna under the group accidental death insurance coverage which she had been paying for through payroll deductions.  Cigna denied Ms. Y’s claim, contending that her husband had died before our client was considered to be in a “Covered Class.”  She was never told that there was a 90-day waiting period for the accidental death benefits coverage to begin and nowhere in her company’s handbook and recruiting materials does it mention a waiting period for accidental death benefits coverage.

Despite everything that indicated our client was properly enrolled in the accidental death insurance coverage, Cigna denied her claim, contending that she was not eligible for the coverage because of an alleged 90 day waiting period found in small print in a multiple page insurance policy that was never given to our client.  Apparently only Cigna was aware of this alleged 90 day waiting period, because the employee relations manager and other employees were baffled by the reason Cigna had denied the claim.

The United States Court of Appeals for the Ninth Circuit in Salyers v. Metropolitan Life Insurance Company, ___ F.3d ___, No. 15-56371 (9th Cir. September 20, 2017) recently rejected an attempt by MetLife to avoid paying a $250,000 death benefit to a widow who had purchased $250,000 in life insurance coverage on her husband prior to his death. In what has recently become an increasingly common scenario, Susan Salyers purchased $250,000 in life insurance on her husband Gary Wolk through a MetLife plan offered by her employer and timely paid all of her premiums on the policy, but MetLife refused to pay the full amount of the death benefit after discovering that Ms. Salyers had not provided the required “evidence of insurability” when purchasing the insurance coverage.

According to the fine print in the MetLife policy, Ms. Salyers was required to submit “evidence of insurability” (proof that her husband was in good health) before any life insurance coverage greater than $50,000 would take effect. However, Ms. Salyers had originally applied for only $30,000 in coverage, and through a clerical error, her employer enrolled her in a policy providing $500,000 in coverage, for which she paid the full premium amounts to MetLife via payroll deductions. At the next open enrollment period, Ms. Salyers elected $250,000 in coverage for her husband, but no one ever told her that she needed to provide “evidence of insurability” in order to obtain this coverage. Nonetheless, MetLife happily accepted her premium payments while never insisting on “evidence of insurability.”  Two weeks later, Ms. Salyers’ husband died.

After the death of her husband, Ms. Salyers submitted a claim to MetLife for the life insurance that she had purchased, but MetLife refused to pay the $250,000 benefit, insisting that she had failed to meet the terms of the policy by not submitting “evidence of insurability.” This was the first time Ms. Salyers had ever heard about a requirement for “evidence of insurability.” Neither the employer nor MetLife had notified Ms. Salyers that she needed to complete further paperwork to be eligible for the life insurance coverage. After MetLife denied the claim, Ms. Salyers sued Met Life, asserting that by accepting her premium payments in the amounts requested for the $250,000 coverage and failing to request evidence of insurability, it was bound to pay the $250,000 death benefit. At trial, judgment was entered in favor of MetLife, and Ms. Salyers appealed to the Ninth Circuit.

The O’Ryan Law Firm has represented numerous employees of Indiana University (“IU”) who have become disabled because of serious illnesses such as chronic pancreatitis, lymes disease, degenerative disk disease, ovarian cancer, and osteoarthritis. A large number of those clients were employees who had worked for Indiana University for many years, some even decades, before reaching the point where they were no longer able to work because of their medical conditions.

Indiana University’s Long Term Disability Plan is an income replacement plan for IU employees who become disabled due to an illness or accident[1].  The following are the general terms of the long term disability coverage provided to IU employees:

  • With claim approval, the plan pays a regular monthly income when an enrolled employee becomes disabled.

Earlier this month, Judge Richard Posner abruptly announced his retirement from the United States Court of Appeals for the Seventh Circuit after more than 35 years on the bench, effective the following day. Judge Posner, a prolific writer and author of more than 3300 judicial opinions and nearly 40 books, was one of the most prominent appellate judges in the United States and the most-cited legal scholar of the 20th century, according to a survey by the Journal of Legal Studies. He carefully drafted his legal opinions to be easy to read and understand, and his signature concise, frank, and often humorous writing style helped to modernize the discipline of legal writing, presenting a stark contrast from the overly formal, long-winded “legalese” that had long dominated the legal field.

Just over three months prior to his retirement, Judge Posner authored an opinionKennedy v. The Lilly Extended Disability Plan, 856 F.3d 1136 (7th Cir. 2017), awarding substantial long term disability benefits to Cathleen Kennedy, an O’Ryan Law Firm client who had been forced to stop working in her position as an HR executive for Eli Lilly & Company as a result of severe fibromyalgia, a nightmarish condition characterized by chronic widespread musculoskeletal pain and fatigue that often presents with psychosomatic symptoms such as sleep and memory issues, anxiety, and depression. Unfortunately, because many of the primary symptoms of fibromyalgia – especially pain and fatigue – are difficult to objectively measure, the condition has historically been misunderstood and often goes undiagnosed due to the lack of a reliable means of testing for it. As a result, those who suffer from fibromyalgia also frequently must deal with the frustration caused by doubts about the validity of their condition and symptoms by friends, family, and sometimes even their healthcare providers.

Fortunately, recent scientific advances in the understanding of fibromyalgia have led to increasing acceptance of the validity of the condition and its profound impact on the lives of those who suffer from it. Judge Posner recognized this in his opinion, noting that Lilly itself markets a treatment for fibromyalgia and has been advised by one of its own physicians that fibromyalgia “is not only very common but is typically also very disabling” and that many victims of fibromyalgia “end up needing to stop working because of this condition.” Nonetheless, Lilly had terminated Ms. Kennedy’s long term disability benefits after she had been disabled for nearly four years due to fibromyalgia, despite the fact that her primary treating physicians had declared her to be permanently disabled, largely because there was no objective laboratory data proving the validity of her symptoms. Lilly claimed that although Ms. Kennedy was unable to work full time in her previous executive-level position, she could still work part time in one of “various non-executive positions” in her field.

O’Ryan Law Firm, on behalf of our client, Jeremy C., recently filed a lawsuit against Liberty Life Mutual after they wrongfully terminated Jeremy’s disability benefits. Our client was employed as a Store Manager with Wal-Mart, which made him eligible for disability benefits offered through the Wal-Mart Stores, Inc. employee benefit plan.  Liberty Mutual is actually the insurance company for the long term disability coverage offered to Wal-Mart employees.

Jeremy worked for many years at Wal-Mart, the last several years as a Store Manager, until he was forced to stop working in March 2015, because of his medical conditions the worst of which was Sjogren’s Syndrome.  Sjögren’s is a systemic autoimmune disease that affects the entire body. The symptoms from this disease include profound fatigue, memory loss, recurrent sinusitis, difficulty with speech, reflux, esophagitis, muscle pain, upset stomach, irritable bowel, peripheral neuropathy and many more.

As a result of Sjogren’s Syndrome, our client suffered specifically from gait instability, memory loss, episodes of dysarthria and slurred speech, overall weakness/fatigue, numbness and tingling in the right arm and right leg, tremors after physical activity, abdominal pain, acute sinusitis, colon polyps, gastroesophogeal reflux disease with esophagitis, exhaustion, and continuous headaches.  The multitude and severity of these symptoms made it impossible for our client to continue handling the responsibilities of a store manager at a large Wal-Mart store located in Lebanon, Indiana.

O’Ryan Law Firm recently filed an appeal for Long Term Disability benefits against Liberty Life Assurance Company of Boston (Liberty Mutual) for wrongfully denying a participant’s benefits. The client was a long time employee of a large financial institution and was forced to stop working due to coronary artery disease, hypertension, diabetes, and ischemic cardiomyopathy. The client underwent a coronary bypass in 2010 and had a dual-chamber cardioverter defibrillator implanted in 2015. He suffers from shortness of breath, fatigue, chest pain, and experiences confusion. The high level of stress with the client’s occupation exacerbated the symptoms correlated to his illness. This stress exposed him to a possibility of a severe cardiac event or even death.

Despite the client’s treating physicians providing objective medical proof that he was unable to continue working full time due to his condition, Liberty Mutual hired a contracted physician to review his claim file. The hired contracted physician contended the client could perform a Sedentary occupation on a full time basis. In addition, the hired contracted physician erroneously claimed the client’s treating physician could perform a Sedentary occupation on a full time basis. When in fact, the treating physician never released the client to return to work full time.

Liberty Mutual originally approved the short term disability claim in full, but then turned around and denied his long term disability benefits based on the hired contracted physician review. In an attempt to solidify the client’s denial, Liberty Mutual hired a private investigator to perform surveillance. The private investigator failed to observe any real activity for four entire days, which was consistent with the client’s limitations. Liberty Mutual cited the following definition of “Disability” within the long term disability denial letter:

O’Ryan Law Firm, on behalf of Plaintiff, William M., recently filed a federal lawsuit against Lincoln National Life Insurance Agency (“Lincoln”).   Lincoln is an Indiana corporation with its main headquarters in Omaha, Nebraska.  William M. was employed by Olon Industries, which made him eligible for Olon Industries’ employee benefit plan.  Part of the employee benefit plan included long term disability coverage which pays 60% of an employee’s salary if an employee becomes unable to work due to sickness or injury.  Lincoln National agreed to insure the long term disability benefits and provided this coverage to the Olon Industries employees.

William M. was employed by Olon Industries until he became disabled in May 2012.  He became unable to work due to a severe stroke, intracerebral hemorrhage, hypertension, permanent vertigo, and partial blindness in his right eye.  His treating physicians provided objective medical proof that he was unable to continue working due to these medical conditions.

Lincoln paid Plaintiff’s claim for disability benefits for 24 months, then they abruptly terminated the benefits with little notice.  Plaintiff internally appealed Lincoln’s decision and in November 2016, Lincoln upheld their decision to deny Plaintiff’s long term disability benefits.  William M.’s doctors never returned him to work even though he was 4 years past his stroke.  As proof that he remained disabled, the Social Security Administration recently reviewed Plaintiff’s claim, and after sending him for a medical exam, concluded that he remains disabled.

The O’Ryan Law Firm recently represented a former employee of Trinity Health, in South Bend, in a lawsuit against Hartford Insurance Company.  Plaintiff worked for Trinity Health as a Food Service Manager for 24 years when she was forced to stop working for Trinity Health because she became disabled in July 2014 mainly due to chronic daily severe headaches.  Hartford Insurance provided disability coverage to Trinity Health employees agreeing to pay income replacement benefits to any employee who became disabled due to injury or illness.

Plaintiff applied for her disability benefits offered through Trinity Health’s employee benefit plan, and insured by Hartford. Hartford approved Plaintiff’s claim beginning in December 2014.  More than 12 months later, on January 12, 2016, a letter from Hartford informed Plaintiff that her benefits would cease on January 13, 2016. In the January 12, 2016 denial letter, Hartford stated, “We have determined that the weight of the medical evidence in your file does not substantiate functional impairment which continues to prevent you from performing Your Occupation on a full time basis. Therefore, benefits are not payable beyond January 12, 2016 and your claim has been closed effective January 13, 2016.”   The Hartford policy has the following definition of “Disability”:

Disability or Disabled means you are prevented from performing one or more of the Essential Duties of:

O’Ryan Law Firm, on behalf of a former employee of Purdue University recently filed a lawsuit against Cigna for wrongfully denying the former Purdue employee’s disability claim.  The plaintiff had was a long time employee of Purdue, worked at Purdue for over 32 years, until he became unable to continue working in May 2013 due to chronic respiratory failure, cardiomyopathy,  recurrent pneumonia, atrial fibrillation, bronchial asthma, and osteoarthritis.  The Purdue employee’s treating physicians provided objective medical proof that the Plaintiff was unable to continue working due to these this combination of symptoms.  Cigna originally approved the claim but then terminated his benefits contending that the Plaintiff could return to work.

Prior to Cigna’s termination of the Plaintiff’s long term disability, a Functional Capacity Evaluation was performed that actually showed that he was unable to return to work. The functional capacity report states, “Mr. R has been off work since 2013 after developing problems with lung infections and difficulty breathing. He shows fair static muscle strength in the lower extremities when seated, however, is unable to functionally use his legs on stairs, working off the floor, getting to the floor, sustained walking and standing. Mr. R. showed a consistent standing limit to 2 minutes at a time.” Throughout the exam, Mr. R demonstrated using a cane to walk, labored breathing and slight wheezing, along with needing to rotate positions and taking multiple breaks. The physical ability assessment concluded Mr. R is only able to stand two minutes at a time, rarely able to walk, and rarely able to lift/carry 0-10lbs.

Under video surveillance conducted by Cigna on 3 separate days, there was no activity on the 1st and 3rd days, and when the Plaintiff was observed, he used a cane when walking

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

According to the National Institute of Mental Health[1], schizophrenia is described as follows:

Schizophrenia is a chronic and severe disorder that affects how a person thinks, feels, and acts. Although schizophrenia is not as common as other mental disorders, it can be very disabling. Approximately 7 or 8 individuals out of 1,000 will have schizophrenia in their lifetime.