Articles Posted in Long term disability denial

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:

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.

According to the Centers for Disease Control and Prevention[1], Chronic Fatigue Syndrome (CFS) is described as follows:

Chronic fatigue syndrome, or CFS, is a devastating and complex disorder. People with CFS have overwhelming fatigue and a host of other symptoms that are not improved by bed rest and that can get worse after physical activity or mental exertion. They often function at a substantially lower level of activity than they were capable of before they became ill.

Besides severe fatigue, other symptoms include muscle pain, impaired memory or mental concentration, insomnia, and post-exertion malaise lasting more than 24 hours. In some cases, CFS can persist for years.

O’Ryan Law Firm, on behalf of Plaintiff, Denise D., recently filed a lawsuit against The Prudential Insurance Company of America (“Prudential”).   Plaintiff was employed by Advance/Newhouse Partnership, which made her eligible for the Advance/Newhouse Partnership Short Term and Long Term Disability Plans, which were administered and insured by Prudential.

Facts of the Case Against Prudential

Plaintiff was employed by Advance/Newhouse Partnership from 2012 until she became disabled in February 2016 and was unable to work due to lupus, fibromyalgia, migraines, spondylosis and radiculopathy. Plaintiff’s treating physicians provided objective medical proof that the Plaintiff was unable to continue working due to these serious illnesses.  Her physicians also confirmed that she was unable to perform the material duties of her job thus meeting the definition of “Disabled” under the Prudential policy.

O’Ryan Law Firm recently settled a lawsuit against American United Life Insurance Company (“AUL”) on behalf of a client whose long term disability benefits were prematurely terminated by AUL.   AUL is headquartered in Indianapolis and has their main office in downtown Indianapolis in the AUL building.  The client, Candace, is actually a New Jersey resident so naturally it would make sense to file the claim in New Jersey.  However, the O’Ryan Law Firm was able to represent Candace in Indiana because of the fact that AUL is incorporated under Indiana law.  As a result, AUL may be sued in Indiana and the lawsuit was therefore filed in the federal district court for the Southern District of Indiana.

Case Against AUL

Candace was employed as an accounts manager for an insurance brokerage company from 2008 until she became disabled in December 2012.  She became unable to work due to lumbar radiculopathy and moderately severe cervical stenosis, both of which resulted in chronic pain and fecal incontinence. Her treating physicians provided objective medical proof that the she was unable to continue working due to these medical impairments.

It’s never too early or too late to hire an attorney to represent you in your disability case. You do not have to wait to be denied by your insurance company before talking to an attorney. We offer several services that can protect your interests. Here are some examples of how we can help:

  • Assist you with your initial application for Long Term or Short Term Disability benefits.
  • Help manage your monthly Long Term Disability benefits.

O’Ryan Law Firm, on behalf of Plaintiff Amy R., recently filed a lawsuit against Sun Life and Health Insurance Company (“Sun Life”). The Plaintiff was employed as an Accounting Clerk with Members Advantage Credit Union for many years which made her eligible for disability benefits under the Members Advantage Credit Union Insurance employee benefit plan.  Her employer provided her with both short and long term disability coverage in the event she became unable to continue working due to a serious illness or injury.  However, the insurance company who insured the benefits, Sun Life, refused to complete their end of the bargain and prematurely terminated Amy’s disability benefits despite the fact her doctors continued to report that she was unable to return to work.

Facts of the Case

Amy was a very hard working and productive employee of Members Advantage Credit Union for over twenty years until she became disabled in 2014 due to the disabling effects of lumbar and cervical herniated discs, back pain, degenerative disc disease, chronic pain, lumbar radiculitis, and osteoporosis.  She had struggled with these conditions for many years but loved her job and did everything possible to continue working as long as possible despite the chronic pain she endured from her multiple back problems.

O’Ryan Law Firm, on behalf of Plaintiff Jo Ellen W., recently filed a lawsuit against Sedgwick Claims Management Services, Inc. (“Sedgwick”). The Plaintiff was employed as a Labor and Delivery Clinical Nurse with Franciscan Alliance which made her eligible for disability benefits under the Franciscan Alliance, Inc. Short-Term and Long-Term Disability Benefit Plans (the “Plan”).

In Jo Ellen W. v .Franciscan Alliance, Inc. Short-Term and Long-Term Disability Plans and Sedgwick Claims Management Services, the Plaintiff filed a lawsuit to gain the long term disability benefits she was entitled to under the terms of the Franciscan Alliance Plan.

Facts of the Case

O’Ryan Law Firm, on behalf of Plaintiff Shane C., recently filed a federal lawsuit against The Prudential Insurance Company of America (“Prudential”). The Plaintiff was employed as Senior Vice President Regional Manager with Custard Insurance Adjusters, Inc. which made him eligible for disability benefits under the Custard Insurance Adjusters, Inc. Long Term Disability Plan (the “Plan”).  As a Regional Manager, Shane was required to travel to 9 different offices throughout the Midwest to oversee and supervise these 9 offices.

In Shane C. v. The Prudential Insurance Company of America and Custard Insurance Adjuster, Inc. Long Term Disability Plan, the Plaintiff filed a lawsuit under ERISA to gain the long-term disability benefits he was entitled to under the terms of the Prudential policy.

Facts of the Case Against Prudential

At the O’Ryan Law Firm, we represent numerous clients who have become disabled and their disability claim was denied by their insurance company. We then represent the clients in the appeal process to appeal the denial of their disability benefits.  Lately, many of the insurance companies have be issuing late determination decisions on the appeals that we submit to those companies.  By law, an insurance company is required to issue a decision within 45 days of the date of receipt of the appeal unless an extension is warranted due to “special circumstances” but even then, a decision on the appeal must be rendered within 90 days at the latest.

The Supreme Court in Firestone Tire & Rubber v. Bruch, 489 U.S. 101, 115 (1989) held that de novo adjudication of employee benefit claims is the norm. Because the de novo standard of review is the default standard in an ERISA employee benefits case, the plan administrator or insurance company bears the burden of showing that the more deferential standard should apply. Fay v. Oxford Health Plan, 287 F.3d 96, 104 (2d Cir.2002)Marguez-Massas v. Squibb Mfg., Inc., 344 F.Supp.2d 315, 320 (D.P.R. 2004); McDonald v. Timberland Co. Group LTD Coverage Program, 2002 WL 122382, at *3 (D.N.H. Jan.23, 2002). Accordingly, once in litigation, a disability insurance company bears the burden of proving that their decision is entitled to deferential review by the Court.

The regulations governing ERISA disability claims require insurance companies to issue a decision on a claimant’s appeal within 45 days of the date that the insurance company received the appeal unless “special circumstances” warrant an extension of time for an additional 45 days; however, in “no event” shall the extension of time exceed 45 days. 29 C.F.R. §2560.503-1(i)(1), (i)(3), (i)(4).