In the unfortunate event that you become unable to work for an extended period of time and are covered under a disability insurance policy, you may find that filing a claim can be a very complicated and frustrating. It’s even more complicated and frustrating if an insurance company denies your claim. The last thing you should have to worry about is fighting an insurance company over your disability insurance claim.
The insurance company or administrator will require you to submit lengthy and confusing applications and forms. Further, the adjuster might require your treating physician to complete a “Attending Physicians Statement” and will probably demand that you gather and provide all of your medical records. You will also usually have to apply for Social Security benefits. Some of this is geared toward building a case to deny your claim and some of it is geared toward developing an offset so that the plan can subtract those monies from your monthly check. If you look closely at your policy, you will almost always find a provision allowing for an offset for “other income.”
If you are making a claim for disability benefits provided through your employer, your claim is almost certainly controlled by the law of ERISA (Employee Retirement Income and Security Act). ERISA is a federal law that started with noble intentions, but has turned into bad law for claimants. Over the years, the law has developed so that the decision to deny or terminate benefits is given great deference by the courts. That is why having a lawyer to help you through the process is so important. You have to provide the right evidence to the adjuster and an attorney can help you plan your strategy.
If you are applying for disability benefits pension benefits, life insurance benefits, or your claim has been denied, call for your free consultation today or send John Dupree an e-mail via the online contact form. Let us know what your problem may be and Mr. Dupree will respond to your e-mail promptly.
Mr. Dupree has devoted himself to helping people overcome the difficulties encountered when seeking disability benefits through an insurance company. Mr. Dupree normally works on a contingency basis – this means that he only gets paid if you are awarded benefits.
Mr. Dupree has experience working on a great variety of cases. Here are some examples of cases he has successfully handled.
The Plaintiff was a thirty-seven-year-old man when he was injured while driving through the parking lot of his employer in Oak Ridge, Tennessee. The Plaintiff was a security guard and noticed skateboarders on the property. He suddenly turned his head to the left and felt a pop on the right side of his neck. the Plaintiff began a course of physical therapy but the Plaintiff had increased pain in his neck which mainly occurred when the Plaintiff was sitting. Also, the Plaintiff’s arm “did not work very well.” An MRI showed herniated discs at the C5-6 level, C3-4 level, and C4-5 level. His physician performed fusion surgery in his cervical spine and then prescribed more physical therapy. the Social Security Administration granted disability insurance benefits to the Plaintiff but CIGNA denied the claim for disability benefits under an accidental disability policy. The reasons for the denial were that “. . . the act of turning your head abruptly is a normal daily activity and cannot be considered an accident.” Further, CIGNA concluded that the Plaintiff’s disability was a result of his ongoing degenerative disc disease rather than accidental bodily injury. After a period of litigation, the matter was settled to the satisfaction of the Plaintiff.
This claimant was a special lady. She was 49 years old with an eighth-grade education (she had to drop out of school to go to work for her family). Further, she had never had the time to earn a GED or a high school diploma. However, through sheer determination, intelligence, and hard work, she progressed in the workforce until she had positioned herself in a management position at a large manufacturing facility in Oak Ridge, Tennessee. Although she had the drive to continue employment, she eventually could not perform the functions of her job because of her constellation of medical conditions and had to apply for disability. She recovered six months' worth of short-term disability but Lincoln denied any payments for long-term disability. Lincoln made a concerted effort to “pigeon hole” the claimant into choosing only one condition as the “primary” condition for pursuing disability. However, no such requirement could be found in any of the terms of the disability plan. Further, Lincoln apparently used two non-practicing nurses’ opinions to support its denial of the claim. Finally, Lincoln asserted that there were no imaging studies, nerve conduction studies or pathology reports to support disability even though these reports and studies would have been useless for many of the claimant’s medical conditions. Following the administrative appeal, we brought suit against Lincoln. Only then, after litigation began, did Lincoln approach settlement. Following negotiations, this matter settled to the satisfaction of the claimant.
This claimant was another resident of Oak Ridge, Tennessee who worked for a contractor for the DOE. He was working as an industrial hygienist when his medical conditions worsened and he could not continue employment. Following an administrative appeal, litigation ensued. As is reflected in the United States District Court for the Eastern
District of Tennessee, settlement was reached in this case by the parties.
This was a Blount County claimant who had stage IV hepatitis C and needed a new liver. He also had a five-level fusion in his lower spine. He was receiving long term disability benefits from Jefferson Pilot for about four years. Apparently, a new adjuster took over his file, looked at the medical records and determined that the claimant was no longer totally disabled. No call to the claimant, no call to the treating physicians – just cut him off. I found out later that Jefferson Pilot did not even have a medical person or vocational person of any kind reviewing the file prior to the termination.
The claimant was in terrible pain from his diseases and was so fatigued that he slept for about 20 hours out of each day. After terminating his benefits, I appealed the decision and Jefferson Pilot hired a consultant in Omaha Nebraska to go in, look at what the adjuster did, look at the medical records and render a determination about the claimant’s ability to work. Through investigation, we discovered that the consultant, Dr. Metcalfe, was an insurance industry utility man. Until May 2004, he was Senior Vice President and Chief Medical Officer (whatever that means) for the Mutual of Omaha Companies. He then operated a medical consulting company out of his home in Omaha - Comprehensive Medical and Legal Evaluations, Inc. He also was the managing partner for an expert witness company called Concipio, LLC. He was no longer treating patients but devoted himself to providing expert opinions and training other experts to provide expert opinions. Without examining the claimant or speaking to the treating physicians (one of whom gave me a sworn statement for FREE because he felt so strongly about this case), Dr. Metcalfe opined that the claimant could hold down a full-time job. Therefore Jefferson Pilot upheld its denial. We fought our way through Jefferson Pilot’s internal appeal process before Jefferson Pilot finally overturned its decision – but not before the claimant received foreclosure papers on his home. Although he managed to save his home, sadly the claimant passed away shortly after we won the appeal. However, near the end, he came to my office on a sunny day doing what he loved to do - riding his Harley Davidson motorcycle.
Although I have represented other claimants with Chrohn’s disease, one, in particular, will always stand out in my memory. This Knox County claimant had 75% of his gastrointestinal tract removed. He had an ileostomy bag that had to be changed every two hours. He had been taking steroids since the late 1970’s – as a result, his bones were brittle and he had permanently broken collar bones that would not heal. He had no more than 2 hours of sleep at a time for years. He had nine surgeries and had spent more than one full year IN the hospital since about 1995. He was constantly in danger of illness – during flu season he did not leave his house for about 2 or 3 months. He once went without solid food by mouth for 18 months. He took a BAG of medication every day. He sold everything he had to pay his bills. He had no pension and he had multiple mortgages on his home. He was in pain every single day of his life.
Nevertheless, in an effort to find meaning in life, during the summer he went to Camp BuckToms in Roane County to help the Boy Scouts for a number of weeks. At the camp, he had an air-conditioned room and a camp physician that stayed in the room next to him – thus he had better care than if he was at home. His job was to counsel homesick boys and attempt to get them to stay at camp. He also served as the camp chaplain. He let the boys know that life is not so bad. Well, Cigna, found out about it and unilaterally terminated his benefits that had been paid regularly since the early 1990s. Cigna asserted that because he could help the Boy Scouts, my client was not totally disabled. Cigna did not call my client, the Boy Scouts or the treating physicians – it simply cut off the benefits without ever advising my client of its intentions. He found out because checks started bouncing. He came to me for help and we fought. We fought hard through the administrative appeal and into litigation in the Eastern District of Tennessee. In fact, I have to say that this case was near to my heart because the claimant was such a good man and he was hurting so badly. During litigation, Cigna never offered to reinstitute the benefits. We had to await the decision of the district court. You can find that 46-page decision at 2009 WL 129799. We settled the case shortly thereafter. While the result was gratifying, the claimant still continues to suffer from his illnesses today.
Feel free to reach out with any inquiries and we will get back to you as soon as possible, we are here to help!
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