Disability Benefits Lawyer & Attorney : Dell & Schaefer : Disability Insurance Claims Law Blog

Ms. Deborah Donovan, an input shift operator for Eaton Corp, was insured under the company’s self-funded group disability plan. Due to degenerative disk disease, chronic back pain and leg pain, Ms. Donovan filed a claim for total disability benefits in 1993.

After ten years of receiving disability benefits, Eaton terminated payment after an evaluation conducted by Broadspire Services Inc. Broadspire claimed there was no objective medical evidence proving Donovan was unable to work. Ms. Donovan appealed, submitting medical records from her doctor which contained evidence of chronic permanent lumbar radiculopathy and severe lumbar degenerative disk disease. Broadspire upheld its denial of benefits and claimed that Ms. Donavan could perform a sedentary occupation. Additionally, Broadspire claimed that a Functional Capacity Evaluation (FCE) proved that she could work.

After several more denied appeals, Ms. Donovan filed suit seeking reinstatement of benefits under the Employee Retirement Income Security Act (ERISA). Ms. Donovan was granted summary judgment, finding that she was entitled to benefits and Eaton appealed.

On appeal, the court upheld the grant of summary judgment, finding that Eaton’s denial of benefits was an abuse of discretion. After reviewing Donovan’s treating physician’s notes, the court concluded that Eaton’s decision to terminate benefits to a claimant with chronic leg and back pain was unreasonable.

• Email This
• Print
• Comments
• Trackbacks

Mr. Mark J. Schwartz, an accountant, was insured under his employer’s group disability plan, sponsored by Metropolitan Life Insurance Co. (MetLife), which limits disability benefits for mental illness to 24 months, but to age 65 for a physical disability.

After major heart surgery in 1999, Mr. Schwartz was diagnosed with post bypass anxiety syndrome resulting in elevated blood pressure, dizziness and chest pain. Upon recommendation by his doctor, Mr. Schwartz applied for total disability benefits that year. The application was granted however MetLife concluded the disability was a result of a mental condition, limiting his benefits to 24 months. In 2001, Mr. Schwartz provided additional medical information arguing his disability was physical in nature. After reviewing these records, MetLife’s doctor concluded there were no physical impairments preventing Mr. Schwartz from working. In May 2001, Mr. Schwartz underwent angioplasty and stent surgery. MetLife denied his claim and terminated his benefits in July 2001. Mr. Schwartz sued in U.S. District Court for the District of Arizona seeking reinstatement of benefits under the Employee Retirement Income Security Act (ERISA).

After reviewing the evidence, Judge Mary H. Murguia held that MetLife could have determined Mr. Schwartz’s disability was physical and under estimated the seriousness of Mr. Schwartz’s heart condition. “Plaintiff’s medically documented disability based on a combination of physical and mental impairments warrants the payment of benefits beyond the 24-month period” stated Judge Murguia.

Mark J. Schwartz v. Metropolitan Life Insurance Co., et al., No. CIV-01-2075, D. Ariz.; 2006 U.S. Dist.

• Email This
• Print
• Comments
• Trackbacks

Sandra Mikolajczyk, an employee of ABN AMBRO North America Inc., was awarded disability benefits for her depression, fatigue, chronic C6 radiculopathy, carpel tunnel syndrome, cholloid brain cyst, multivalve prolapse, cervical disc surgery, anterior cervical neural decompression and other disorders. Ms. Mikolajczyk was insured by her company’s group disability policy with Broadspire Services, Inc.

After two years of benefits, Broadspire terminated Ms. Mikolajczyk’s coverage. Prior to canceling Ms. Mikolajczyk’s benefits, Broadspire had select documents from her medical record reviewed by Dr. Vaughn Cohen. Dr. Cohen determined that Ms. Mikolajczyk lacked functional impairment that prevented her from working as a bank branch manager. Broadspire physician, Dr. Jamie Wancier, conducted a medical record review and found Ms. Mikolajczyk able to perform full-time sedentary work. Ms. Mikolajczyk promptly filed suit seeking benefits under the Employee Retirement Income Security Act (ERISA).

Judge Katz of the Northern District of Ohio stated that Broadspire “relied on document reviews that were incomplete and went against the weight of the administrative evidence”. Judge Katz further noted that “Broadspire’s refusal to conduct a physical examination, even when tests were recommended by its own reviewing physician, is another factor that weighs against the reasonableness of defendant’s denial of benefits.” Lastly, the court held that Broadspire should have considered the favorable award of social security disability benefits. Broadspire was ordered to pay disability benefits. Opinion available at Sandra Mikolajczyk v. Broadspire Services Inc., No. 3:05-CV-7039, N.D. Ohio.

• Email This
• Print
• Comments
• Trackbacks

June 23, 2006, U.S. District Judge Joe B. McDade of the Central District of Illinois Ruled in favor of Susan Svejda, an employee of Mercantile Bancorp. Ms. Svedja was employed with Mercantile until 2002. After several visits to physicians and her neurologist, Dr. Douglas Sullivant, M.D., Ms. Svedja was diagnosed with MS, Chronic imbalance, depression and bowel problems including IBS (Irritable Bowel Syndrome) which require her to frequently rush to the bathroom, often times not making it due to other infirmities. As a result of these conditions, Ms. Svedja stopped working and applied for long-term disability benefits from Mercantile’s insurance contract with Continental.

Continental had Ms. Svedja’s medical records reviewed by their physician, Dr. Eugene Truchelet, who concluded there was not enough information regarding Svedja’s bowel problems to conclude whether she merits long term disability benefits, however she would require some workplace limitations including being close to a restroom.

An investigation ensued, and Ms. Svedja’s physical demands at the office were examined. The conclusion was that Ms. Svedja required to be placed in close proximity to a restroom due to her bowel complications. Mercantile claimed it was not feasible to move Svedja’s desk to accommodate her. Mercantile subsequently denied Svedja’s claim and she promptly filed suit seeking benefits under the Employee Retirement Income Security Act (ERISA).

Judge McDade stated that Continental’s denial of Ms. Svedja’s claim was unreasonable under an arbitrary and capricious standard of review. Judge McDade stated Continental “chose to completely ignore the unfavorable information that Mercantile submitted about not being able to move Ms. Svedja’s desk close to a restroom, which would allow her to continue to work,” and “failed to provide a specific reason for denial of benefits when they ignored doctors’ opinions.”

Judge McDade found that Ms. Svedja is entitled to benefits under the disability policy. Susan Svejda v. Mercantile Bancorp Inc., et al., No. 04-1263, C.C. Ill.

• Email This
• Print
• Comments
• Trackbacks

Rosa Wood had carpel tunnel syndrome and left work in 1999 because of it. After receiving short term disability benefits and undergoing back surgery, Ms. Wood applied for long term benefits. Initially, Ms. Wood’s claim for benefits was denied however her plan eventually agreed to pay benefits for the first phase of long term disability. Under the first phase, claimants are entitled to benefits for seven to twenty-nine months based on their ability to perform any substantial gainful work. Prudential then denied long-term disability benefits to Ms. Wood during the second phase which would continue benefits beyond the twenty-nine months. After two internal appeals, Ms. Wood sued Prudential in Federal Court.

The court ruled that any “reasonable trier of fact would find Wood to be disabled” and rejected Prudential’s attempt to limit the claim. The judgment was based on evidence stating no factual dispute that Ms. Wood was diagnosed with carpal tunnel syndrome in 1999 and that she had spinal surgery in 2000 and continues to suffer from pain and numbness in her hands. Reports from all of Ms. Wood’s examining physicians support her disability claim with the exception of Dr. Teital who examined Ms. Wood at the request of Prudential. Dr. Teital did not find that Ms. Wood was exaggerating her symptoms.

Additionally, Prudential’s consulting physician, Dr. Ito, did not examine Ms. Wood nor did he dispute Ms. Wood’s diagnosis or the findings of pain from her other doctors. However, Dr. Ito apparently discounted Ms. Wood’s pain limitations on the basis that they were not supported by objective testing. Prudential’s policy did not require the type of testing Dr. Ito required supporting Ms. Wood’s limitations.

Further, Sandra Richter, a vocational counselor who met with Ms. Woods during her first phase of long term disability benefits, concluded that she is totally disabled. Two other vocational reports were written without meeting Ms. Wood and submitted during the evaluation of second phase LTD benefits. These reports were prepared based on limitations that did not include limitations of her use of extremities. Neither of these reports included analysis of the “gainful employment” language of Prudential’s policy which explained that “gainful occupation” is defined as an occupation that provides at least sixty percent of pre-disability earnings. Prudential must now pay all past due long-term disability benefits to Ms. Wood and re-calculate her claim for the future.

• Email This
• Print
• Comments
• Trackbacks

Lawrence Levy, M.D., insured under two disability policies with Minnesota Life Insurance Co., became disabled in March 1996 and has been receiving total disability benefits due to osteoarthritis in his right knee. Dr. Levy claims his disability is an “injury” rather than a “sickness” because the osteoarthritis is due to a basketball injury. The policy provides disability benefits to the age of 65 if the disability is caused by “sickness”, disability benefits will be paid for life is the disability is caused by an “injury”.

U.S. Magistrate Judge Sidney I. Schnekier said the best interpretation of the policy is the term “immediate cause”. Under the immediate cause standard, Dr. Levy’s disability is due to sickness. The Judge stated the knee pain is due to degenerative arthritis and should characterize as a “sickness” under the long-term disability policy. Dr. Levy’s benefits will terminate at age 65.

Lawrence B. Levy, M.D. v. Minnesota Life Insurance Co., No. 03-C-5141, N.D. Ill.; 2006 U.S. Dist.

• Email This
• Print
• Comments
• Trackbacks

Robert Clarke, a market sales manager for Allstate Insurance Company, stopped working in 1992 due to lumbar spinal stenosis, claiming he was unable to sit, stand, or walk for more than 10 minutes. Mr. Clarke was insured under his company’s group disability plan administered by Metropolitan Life Insurance Co. and was paid total disability benefits as of 1992. After several back fusion surgeries in 1990, 1992, and 1994, MetLife approved Mr. Clarke’s initial claim for benefits. In 2202, after paying total disability benefits for more than 10 years, MetLife decided to terminate Mr. Clarke’s disability benefits and claim that Mr. Clarke could perform sedentary work.

In June 2000, MetLife began video surveillance of Mr. Clarke. The video tapes were reviewed by MetLife’s doctors including an occupational therapist and functional capacity evaluation coordinator. In May 2002, MetLife terminated Mr. Clarke’s disability benefits stating Mr. Clarke’s restrictions and limitations are inconsistent with the video surveillance and medical records. MetLife upheld its decision on appeal and Mr. Clarke sued in the U.S. District Court for the Southern district of Ohio, for reinstatement of benefits under the Employee Retirement Income Security Act (ERISA).

After reviewing MetLife’s denial of disability benefits, Judge Michael R. Barrett stated that MetLife’s reliance on videotaped surveillance in its decision to terminate Mr. Clarke’s benefits was arbitrary. “MetLife’s assertion that plaintiff’s misrepresentation of his functional limitations somehow invalidated objective medical evidence is unreasonable” ruled Judge Barrett. MetLife was ordered to pay back-benefits to Mr. Clarke and reinstate his disability benefits.

Robert B. Clarke v. Metropolitan Life Insurance Co., et al., No. 1:04-cv458, S.D. Ohio; 2006 U.S. Dist.

• Email This
• Print
• Comments
• Trackbacks