Articles Tagged with “disability insurance”

O’Ryan Law firm has extensive experience representing clients in appeals and litigation under the Employee Retirement Income Security Act of 1974 (ERISA), which governs most claims for benefits under employer-sponsored insurance plans. Earlier this year, the US Department of Labor amended its regulations under ERISA, providing claimants with some additional rights during the process of appealing denials of benefits under plans governed by ERISA.

One important additional right granted under the new ERISA regulation is the opportunity to review and respond to any additional evidence considered by an insurance company during an appeal of a benefits claim denial. This means that if a claimant appeals a denial or termination of benefits and the insurance company sends the file to a reviewing physician, the claimant has a right to read and respond to the report of that reviewing physician before the insurance company can make its final decision on the appeal. O’Ryan Law firm recently took advantage of this new protection to obtain short term disability (STD) benefits for a client who had previously had her STD benefits terminated.

Kim M was a Repair Service Attendant at a large telecom company and was forced to stop working in early 2017[1] as a result of failed back syndrome, multilevel degenerative disc disease, lumbar facet arthritis, and spondylopathy. After she was unable to return to work, she was awarded STD benefits under her employer’s disability plan, which was administered by Sedgwick. However, Sedgwick terminated Kim’s STD benefits several months later, claiming there was no longer sufficient medical evidence to support her claim. In the letter explaining its termination of Kim’s benefits, Sedgwick relied on the opinions of two reviewing physicians who asserted that Kim was not disabled.

When completing an application for life, health or disability insurance coverage, an insurance company will ask a broad array of questions designed to determine whether an individual is a good risk and the type of coverage that should be issued. It is important to carefully complete the application form to make sure that all of the answers are 100% accurate; otherwise, the insurance company may later deny your claim. Unfortunately, many people do not find out that they failed to disclose important information on the insurance application until a claim is submitted. The insurance company then denies the claim contending that the insured made a material misrepresentation in the application because the insured failed to disclose important information such as a previous health condition or by their failure to answer “yes” to questions which were answered “no.” If the misrepresentation is material to the insurer issuing coverage, the insurance company has the right to deny the claim, rescind the policy and refund the premiums that have been paid.

The falsity of any statement in the application for any policy may not bar the right to recovery thereunder unless such false statement materially affected either the acceptance of the risk or the hazard assumed by the insurer. (IC 27-8-5-5(c)). False representations on an insurance application made by an insured concerning a material fact, which mislead, will void an insurance contract, just as in any other contractual relationship, regardless of whether the misrepresentation was innocently made or made with fraudulent intent. Ruhlig v. American Community Mut. Ins. Co., 696 N.E.2d 877, 880 (Ind. Ct. App. 1998) citing Watson v. Golden Rule Ins. Co., 564 N.E.2d 302, 304 (Ind. Ct. App. 1990); American Family Mut. Ins. Co. v. Kivela, 408 N.E.2d 805, 810 (Ind. Ct. App. 1980); Bennett v. CrownLife Ins. Co., 776 N.E.2d 1264 (Ind. Ct. App. 2002); Jesse v. American Community Mut. Ins. Co., 725 N.E.2d 420 (Ind. Ct. App. 2000).
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