We spend a lot of time on this blog discussing the dubious, sometimes nefarious tactics insurance companies will use to deny or terminate long-term disability benefits, especially those claims covered by ERISA. Although every claimant has a right to sue the insurance carrier if a claim has been wrongly denied, depending on which state you live in, such claims are frequently not successful. But there are also plenty of examples of claimants being successful in court against an insurance carrier, so there is always reason to consider litigation when all else fails.
An ERISA lawsuit comes with uncertainty, existential stress and an extraordinary amount of effort for someone too disabled to work. These are experiences no one should have to endure. However, considering the near bottomless resources, medical professionals and expensive lawyers that insurance carriers hire instead of paying out benefits, a court victory deserves a well-earned celebration. Here are a few examples to boost morale and confidence should you find yourself in such a position.
An irritating, if easy slam dunk decision
In Pifer v. Lincoln Life Assurance Co. of Bos., the list of “major flaws” that the court identified in this case must have been amusing to witness–although not to experience as the claimant. It’s also an important reminder that insurance companies and their employees are often just as confused about their internal processes as the rest of us.
Among Lincoln’s many faults was its mystifying decision to cancel benefits in the first place, considering that there had been no changes or improvements in the plaintiff’s condition; the failure to provide its own reviewing doctors with the relevant medical records; ignoring evidence favorable to the plaintiff; and the complete disregard for the plaintiff’s subjective accounts of her symptoms and pain.
This case is also noteworthy in that the plaintiff had been receiving benefits for 10 years before Lincoln made the seemingly arbitrary decision to terminate them. The lesson here is never throw out your ERISA attorney’s contact information.
Sometimes, denials appear to be based on pure fiction
Moving from incompetence and neglect to utter deceit, we have the case of Graziano v. First Unum Life Ins. Co., which we highlighted previously. This is another example of a lawsuit that any fair-minded observer could have quickly resolved without a law degree or even prolonged consideration.
The plaintiff’s numerous physical ailments prevented him from something as sedentary as sitting at a desk for long periods. Unum didn’t even try to make this denial of benefits look legitimate, assigning a case reviewer who had no experience in pain management or rehabilitation. Also, as is often the case, the reviewer never saw or spoke to the plaintiff.
Overshadowing that half-hearted effort was a glaring mischaracterization in the denial, claiming that the plaintiff’s efforts at rehabilitation were “conservative.” In fact, the plaintiff’s medical records detailed his earnest pursuit of treatment, including steroid injections and radiofrequency ablation treatments, even as his symptoms worsened.
If a denial confuses you, it will probably confuse a judge, too
It’s tempting to assume you don’t understand convoluted insurance policies because seemingly only someone with a law degree and insurance expertise could unravel all that jargon. But sometimes, it just plain doesn’t make sense.
In Mucciacciaro v. Hartford Life & Accident Ins. Co., a case so simple that it was resolved without a trial, Hartford attempted to move the goalposts at both ends of the field. The plaintiff continued to work through significant pain while she waited for a ruling on her application for long-term benefits. Hartford denied her benefits, arguing that the plaintiff was still working and therefore could perform her job. They further argued that she would quit her job if she truly suffered debilitating pain.
Of course, had she quit, she would no longer be eligible for benefits. The court’s rebuke illustrated this poorly concealed “catch-22” and ordered Hartford to start fresh on the plaintiff’s application.
A legal professional should review a denial of benefits
The overarching takeaway from these stories is that challenging questionable insurance company decisions never hurt anyone. Overtly dishonest denials like the examples above happen because insurers know only a fraction of people pursue their cases after a failed appeal. Those benefits go right to the carrier’s “bottom line” ie, profits.
The lesson? Never take “no” for an answer. Get the legal help you need, when you need it, to evaluate a denial of benefits to assure that you are being treated fairly, and that the denial of benefits is not simply a ploy to increase the insurance company’s profits.