Employees in Chicago who appeal denied long term disability insurance claims without an attorney can feel like driving a car with their eyes closed. They feel the process may be adversarial, and the insurer knows how to present a denial, and the claimant does not know how to address it or rebut it. It often takes more than medical evidence. The purpose of the appeal is not just to show you are disabled, but to get an insurer to pay the claim, which are two different results. One of the ways insurers will deny a claim, or uphold a denial, is to reject objective test results, like an MRI or Functional Capacity Evaluation, by reasoning the results came after the claim denial, or after you stopped working. The insurers want you to believe that evidence means less, because you could have had an additional injury, or your condition could have gotten worse by the time of the examination, but that it was not yet disabling when you stopped working. While this approach may make you believe you have no case, a good lawyer will not only be able to get a court to reject that reasoning, but get the insurer to retreat from it before denying your claim (so you never have to get to court). A recent example of insurers still trying to use the “time concurrence” argument sprung up in another recent case.
In Zuke v. American Airlines Long Term Disability Plan, No. 15-3465, 2016 U.S. App. LEXIS 6086 (6th Cir. Mar. 31, 2016), Mar-Ya Zuke worked for American Airlines as a sales and service representative, but stopped working in December 1998 from severe injuries following a serious car accident. After paying Zuke long term disability benefits for 13 years, MetLife terminated the benefits, citing a lack of objective evidence in the records to support ongoing payments. With her second appeal request, Zuke’s long term disability attorney submitted comprehensive medical examinations including MRIs, report of physical examination by a doctor, and evidence of treatment for epidural lumbar injections for pain. The records revealed extensive degenerative disc disease, disc herniation, and reduced range of motion in the cervical, thoracic, and lubrosacral spine. MetLife upheld its decision, referring to the appeal submission as an “absence of objective medical/clinical evidence to substantiate total disability.”
Zuke sued MetLife and the plan under ERISA § 502(a) to recover her benefits. The district court upheld MetLife’s decision. But the United States Court of Appeals for the Sixth Circuit reversed. That court reasoned that it was arbitrary and capricious to terminate the benefits. The record before the court contained objective and reliable evidence that MetLife ignored when it asserted there was no objective evidence. Such conduct does not provide a full and fair review under 29 U.S.C. § 1133.
If you have a claim for long term disability insurance, and the insurer claims there is a lack of “objective evidence,” speak with an experienced ERISA long term disability lawyer right away.