Serving Alabama and the Southeast
Long Term Disability Overview
You Need an Attorney on Your Side
David P. Martin has ERISA experience. For over 14 years he has represented persons with long term disability claims. Insurance companies know about ERISA and how to use it to their advantage. Those with claims need an experienced attorney to level the playing field for them. A district court judge in Loucks v. Liberty Life Assurance, 337 F. Supp. 2nd 990, 991 (W.D. Mich. 2004) gave a colorful warning as to the abuse that frequently occurs in the handling of a disability claim. This warning underscores the need to obtain an attorney familiar with ERISA early on in the long term disability claim process:
Caveat Emptor! This case attests to a promise bought and a promise broken. The vendor of disability insurance now tells us, with some legal support furnished by the United States Supreme Court, that a woman determined disabled by the Social Security Administration because of multiple disabilities which prevent any kind of work cannot be paid on the disability insurance she purchased through her employment. The plan and insurance language did not say, but the world should take notice, that when you buy insurance like this you are purchasing an invitation to a legal ritual to which you will be perfunctorily examined by expert physicians whose objective it is to find you not disabled, you will be determined not disabled by the insurance company principally because of the opinions of the unfriendly experts, and you will be denied benefits..."
The court concluded, “Although this Court regularly upholds claim determinations under the ‘arbitrary and capricious” standard, in this case the claim administration was precisely that.” Id. at 991. The court granted the plaintiff’s motion for entry of judgment and denied the defendant’s motion, and further gave leave for the plaintiff to seek attorney’s fees and costs.
The case was later settled and the opinion vacated which means it is no longer a published opinion. The insurance company in effect paid a settlement to hide the stern comments from the judge from the public eye. The full opinion however was downloaded by David P. Martin before it was vacated for those interested to see. It highlights an all too frequent problem which underscores the need of claimants to hire counsel familiar with ERISA early in the claim process. For broader coverage on issues invovling other benefits as well as long term disability go to www.erisacase.com
Courts Have Struggled With ERISA
Judge Acker, a federal district court judge in the Northern District of Alabama has written on his judicial observations of the unfairness of ERISA. See, Judge William M. Acker , "Can the Courts Rescue ERISA," 29 Cumb.L.Rev. 285 (1998/99): He thoughtfully and forcefully stated "Since writing Florence Nightingale, I have changed my mind. ERISA is beyond redemption. No matter how hard the courts have tried, and they have not tried hard enough, they have not been able to elucidate ERISA in ways that will accomplish the purposes Congress claimed to have in mind."
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Courts May Treat You as If you Should Know ERISA and Your Plan
Another reason to hire ERISA counsel early in the claim process is found in a recent opinion from Florida. Judge Corrigan from the Middle District of Florida ruled that a claimant's letter from her doctor saying she was unable to work, and records submitted late, meant that MetLife was correct to deny the disablility claim. This was because consideration of the late submitted records was not permitted. MetLife's conflict - it was deciding a claim that would cost it money if paid -- also didn't matter. The truth of the matter was not as important as following the time frames given by the process and the insurance company. Here are excerpts of the opinion.
BRANDY SNIDER, Plaintiff, vs. CINGULAR WIRELESS HEALTH AND WELFARE BENEFITS PLAN FOR NON-BARGAINED EMPLOYEES, etc., et al., Defendants. Case No. 3:04-cv-198-J-32MMH UNITED STATES DISTRICT COURT FOR THE MIDDLE DISTRICT OF FLORIDA, JACKSONVILLE DIVISION 2006 U.S. Dist. LEXIS 58400 August 18, 2006,
Decided MetLife's decision to terminate Snider's STD benefits as of April 30, 2003 was not "wrong." MetLife provided STD benefits to Snider from December 16, 2002 through April 30, 2003 due to a disc protrusion in her back that resulted in a microdiscectomy. Plaintiff posits that the termination of benefits as of April 30, 2003 was wrong and unreasonable because MetLife failed to provide a sufficient discernible reason why benefits were terminated. Defendants submit that plaintiff failed to show any entitlement to benefits post-dating April 30, 2003 and that the objective medical evidence received as of that date was consistent with a decision to terminate benefits.
After the termination of STD benefits on April 30, 2003 and before the appeal denial on July 15, 2003, the only additional medical evidence that plaintiff submitted to MetLife was Dr. DiSclafani's May 5,2003 letter, which essentially provided that she was suffering from chronic back and leg pain and that she was unable to work. (A.R. 074). There were no medical records or reports that accompanied the letter, and, throughout the appeal process, plaintiff submitted no additional medical records documenting her condition until after the close of her appeal on July 15, 2003. n5 Further, despite MetLife's repeated requests for additional medical records in February, March and April 2003 for all medical notes pertaining to Snider spanning that period, the only other information that Snider provided prior to MetLife's appeal decision was her January 27, 2003 operative report (A.R. 060-062), the January 28, 2003 hospital discharge summary (A.R. 063) and Dr. DiSclafani's April 16, 2003 Supplemental Attending Physician Statement (A.R. 068). .......... While Snider focuses on the fact that she was unrepresented during this period and confused about what she needed to do, that alone does not obviate the requirement that she meet her burden of proof to show that she is entitled to continuing STD benefits.
The Summary Plan Description is clear that STD benefits are no longer payable if the claimant has "not established [his or her] Disability based on credible objective medical evidence, as determined by the Claims Administrator," (Doc. 72-4 at p. 10), and that the claimant "[is] required periodically to provide the Claims Administrator with supplemental medical information from [his or her] physician documenting [his or her] continued Disability," (Id. at p. 13). Other than the January post-operative documents, the April 16, 2003 Supplemental Physician Statement and Dr. Disclafani's May 5, 2003 letter, Snider provided no medical evidence that she was entitled to continuing benefits after April 30, 2003, and thus failed to carry her attendant burden under ERISA. See Horton, 141 F.3d at 1040. Moreover, MetLife had the independent report of Dr. Soriano (neurosurgeon) dated July 14, 2003 n6 that supported a finding of no disability. Thus, MetLife was not "wrong" to determine there were no medical findings post-dating April 21, 2003 justifying Snider's subjective complaints of pain. n7 ........
Moreover, Snider's claim that MetLife failed to comply with 29 U.S.C. § 1133(1) because it failed to set forth specific reasons for the denial of STD benefits to Snider after April 30, 2003 is unavailing. The April 30, 2003 denial letter specifically provides, inter alia, that: [a]fter reviewing the Attending Physician Statement, signed by Dr. Disclafani on April 16, 2003, the medical provided is not supportive of significant functional impairments preventing you from being able to return to work as a Customer Service Representative. The medical provides minimal objective findings that support functional impairments. There also have been no physical exam findings to support continued functional impairments. (A.R. 072-073). The letter also set forth the definition of "Total Disability" under the Plan, thus informing Snider that the medical information she provided did not support a finding that her malady fell within that definition. (Id.). The denial letter fully explained Snider's right to appeal, informed her how to do so and explained that if her appeal was denied, she could file suit under ERISA. (Id.). n8 MetLife did not violate any claims procedures in the manner in which it informed Snider as to its decision, and sufficiently complied with 29 U.S.C. § 1133(1) and 29 C.F.R. § 2560.503-1(e)(g) in terminating her STD benefits. [*30]