Winning Appeal Gets Long Term Disability Benefits Reinstated in DC
Here's the story of how a hard working single father got Hartford to reverse their decision terminating his long term disability benefits after coming to us for an appeal.
Or client had a physical job, working as a machinist and welder, a job he loved and had done for years. His father taught him how to work with tools when he was a young kid, and as he got older, taught him how to weld and fabricate. He was happy to go to work every day.
A supervisor at his job didn't follow safety protocals for grounding electricity, despite repeated warnings, or didn't understand the importance of working with high voltage electricity. When the welder went to work, thinking the area was safe, he received an electric shock that travelled up his arm, causing pain and nerve damage.
Since he was on the job at the time of this injury in Washington, D.C., we were able to get him workers comp benefits for the injury, and a settlement of his DC workers comp claim because he could not return to his heavy duty occupation.
Fortunately, his employer also had a long term disability insurance policy that provided for disability benefits for serious injuries and medical conditions.
The Long Term Disability Application Process
Like most insurance companies, Hartford had forms to complete to get the process started. They wanted medical records and job information and had to verify with the employer that he had not returned to work.
He did the initial application on his own, like most people. He signed all the forms and paperwork. He submitted his medical records and his doctors said he could not return to work because of his injuries. But the insurance company always wanted more information, which was fine - he wasn't trying to hide anything.
And Hartford finally approved his claim for long term disability! Problem was, they denied it about a week later, saying he was no longer disabled under the policy (I'm not making this up - it was that quick.
A Peer Review Doctor Who Had Never Seen the Patient Said He Could Go Back to Work.
That was the reason for the denial of benefits after they had awarded benefits - a doctor who had never seen this worker read his medical records and said he could return to his regular occupation. This happens all the time in long term disability claims. The insurance company relies on these doctors (who charge a fortune for their service) to read a few medical records and give an opinion that a worker is not disabled, doesn't need treatment or his disability is caused by some other condition that is not covered by the policy.
We Filed an Appeal of Hartford's Denial of Benefits
Since we represented him in the original injury against his company, we knew this man was legitimately injured and honest. And that he had a family to provide for.
Every appeal starts with analyzing the entire claim file the insurance company has (our request for an insurance company claims file in these cases lists approximately 30 different types of documents, media and information) and the long term disability insurance policy.
In this case, we attacked the peer review doctor's opinion as incomplete (giving specific medical evidence that he had not considered in support) and we worked with this worker's treating physicians so they expressed their opinions that he could not return to work in light of the definitions, terms and conditions in the insurance policy (it is absolutely critical to educate the physicians on exactly how each policy defines disability).
We arranged for medical testing that his physicians could consider as support for their opinions, and which the peer review doctor had never seen or contemplated.
Naturally, our medical research professional analyzed the current state of the literature on our worker's medical condition and the effects of the various medications he was prescribed for the problems his injury caused.
Plus we did a deep dive into the peer review doctor's background - our extensive medical research process always includes opposition research on the insurance doctors.
We interviewed others with the same occupation to see what the real job duties were, rather than relying on a paper, corporate version of his job description - and they were quite different.
We drafted witness statements, including one from our worker describing his life, his job, his injury, his symptoms and and why he could no longer work at his heavy duty job (a trade his father taught him as a boy - so you can imagine how powerful this was).
An Appeal of an Insurance Company Denying Long Term Disability Benefits Has to Overwhelm the Insurance Company
Our standard appeals are 28 - 33 pages long and can contain hundreds of pages of exhibits and supplemental material.
Why do we focus on an appeal that combines medicine, law, the policy terms and conditions, new evidence and testing, witness statements, medical literature, etc.? These are difficult cases - the insurance policy always favors the insurance company - so we want to really show the disability insurance company that they were wrong, and support it every step of the way.
And if your appeal is denied under ERISA (the federal law that governs most long term disability policies) the next step is to file a lawsuit in federal court, where a federal judge will decide whether the insurance company acted reasonably by denying your benefits, based upon the administrative record, including your appeal and evidence.
There are no chances to create evidence once you file your federal lawsuit under ERISA, which is why you need an experienced long term disability attorney working for you early in the process.
Our case had a happy ending - the father of 4 was awarded all of his past due long term disability benefits, about 16 months worth, plus ongoing monthly benefits.
Our Long Term Disability Benefit Attorneys Can Help if You've Been Denied
Call us today at (202) 393 - 3320 to get started working with us. But don't wait, under ERISA and most long term disability benefit insurance policies, you only have 180 days to appeal - not a lot of time for the amount of work you need to do if you want to do it right.
If you received a letter denying or terminating benefits, we'll analyze the insurance company's position and make recommendations on your next steps for free with absolutely no obligation.
You can email the letter to us at [email protected] or fax it to (202) 393 - 3324