Denied Disability Insurance
Both short-term disability and long-term disability policies are purchased as insurance to protect you in the event that you become disabled and can no longer work. But countless policy holders are denied disability insurance by insurers who employ bad faith practices. Experienced long-term disability insurance lawyers can help consumers appeal wrongly denied disability claims and file a long term disability lawsuit.
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Denied Disability Insurance
Short-Term Disability Denial—Am I Eligible for Benefits?
These benefits can be funded and administered by an insurer or funded by the employer and administered by a third party administrator. The employer is usually involved with a short-term disability claim.
If you are denied short-term disability, you have the right to appeal. Disability insurance attorneys advise you to examine your policy and make sure your disability falls within its definition of STD. Next, have your physician re-evaluate your condition and obtain a copy of your medical record—it will be required as evidence with your appeal. Lastly, consult with a bad faith insurance attorney who is experienced in short-term disability claims.
Long-Term Disability Denial—Am I Eligible for Benefits?
Most people believe their long-term disability (LTD) benefits cover injuries that are work-related only. However, it is estimated that more than 95 percent of LTD claims are non-work related, such as chronic diseases, mental illness and cancer. These illnesses and more may be covered on your LTD benefits policy.
If you have made a claim under a long-term disability policy and have had your claim denied, or if your claim was approved and then later terminated, you have the right to appeal and an attorney can help determine if you are eligible for substantial additional benefits.
Long-term disability policyholders in Washington, Oregon, Hawaii, Alaska, Montana, Idaho, California, Nevada and Arizona who have had their LTD claims unfairly or unreasonably delayed or denied may be eligible to file a lawsuit against their long-term insurance company.
Long-term insurance companies that have or could face a denied disability claim include Cigna, The Hartford, Aetna, Lincoln Financial, Sunlife, Prudential, Liberty Life, Reliance Standard, Sedgwick, Dearborn National, MetLife, Principal Financial Group, Guardian Life, The Standard, Mass Mutual, Union Central, Lloyd's of London, Illinois Mutual, Assurity and Fidelity Insurance Group.
Denied Disability Lawsuit
Wrongfully Denied Disability and ERISA
ERISA is a government statute comprising a series of regulations. These regulations, however, are rarely enforced by the Department of Labor, thereby allowing the insurance industry to employ bad faith practices and denying your claim. Because ERISA is so complicated and evolving, you need an experienced attorney to understand and identify bad faith tactics by the insurer.
The ERISA law regulates most every aspect of employee welfare benefits. Even though it is a complex set of rules, ERISA was set up in 1974 to give you the right to pursue a lawsuit in federal court. Be aware that a disability lawsuit occurs before a judge only (no jury) who will review only those administrative documents on record—you seldom have a second chance so it is imperative that you seek an experienced ERISA attorney.
To file an ERISA claim you must do the following:
File an initial claim with your insurer and typically within 45 days a claims reviewer will determine whether you are entitled to disability benefits
If you are denied benefits, you can either accept that decision or appeal for another review by the insurance company. The insurance company must explain to you the reason for their denial.
Be aware that both processes involve deadlines, which should be clearly defined in your letter of denial. As a rule, you will have only 180 days to file an administrative appeal of the denial.
If you fail to meet these deadlines, you may lose all rights of appeal and your right to file a wrongfully denied disability lawsuit.
If you have appealed your case under ERISA and haven't received a decision within 45 days, disability insurance lawyers advise that you file a lawsuit sooner than later. It is advantageous for you that a judge receives documentation from your attorney rather than just reviewing documentation from the insurance company that denied your claim.
For more ERISA information visit The Department of Labor(DOL) website and ERISA commonly asked questions.
Common Claim Denials
Bad Faith Disability Insurance
Besides intentionally denying a claim, Insurers are well-versed in a number of insurance denial tactics, such as:
- Misclassifying injuries and/or insisting your medical condition is pre-existing
- Denying your medical records and/or claiming you lack "objective medical evidence"
- Relying on evidence by their independent medical examiner
- Partial payments on disability claims
- Unreasonable denial, delay, or policy termination
- Concealing benefits from policyholders
- Insisting you are able to work in another occupation
Register your Denied Disability Claim ComplaintIf you or a loved one has been Denied a Short-Term or Long-Term Disability claim, you may qualify for damages or remedies that may be awarded in a possible lawsuit. Please fill in our form to submit your complaint and we will have a lawyer review your Insurance complaint.
At LawyersandSettlements.com, it is our goal to keep you informed about important legal cases and settlements. We are dedicated to helping you resolve your legal complaints.
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Unum Disability Insurance Claimant Wins Reinstatement of LTD Benefits
Jury Awards $25.6 Million in Bad Faith Insurance Lawsuit
Through his attorney, he alleged that “Aetna’s denial of her claim involved overworked, under-qualified doctors working in the interest of their employer’s bottom line who are compensated in part based on the profitability of the company.”
The jury apparently agreed; nearly $10 million of the award is in the form of punitive damages, intended to punish the insurer for bad faith.
Over-worked, Under-qualified Medical Reviewers
Evidence was presented at trial that none of Aetna’s in-house medical reviewers was a specialist in proton beam cancer therapy. One was an internal medicine/family practice doctor who had not treated a patient in 25 years. Another was general surgeon, and the third was a hematologist/oncologist who had no experience with radiation therapy. None had spent more than 30-45 minutes reviewing the claim for treatment, and at least one had complained in an official personnel file of having to review 80 or more claims per day. None had read the insurance contract before denying the claim.
One of the reviewers allegedly spoke to a doctor treating Ms. Cunningham and acknowledged that the treating doctor’s recommendation for proton therapy was appropriate. However, he said that he had to deny the claim anyway.
Routine Denials for Innovative or Advanced Treatments
Proton beam therapy is an FDA-recognized treatment, often approved for pediatric and Medicare patients. It allows doctors to precisely focus cancer-fighting proton energy on cancerous cells, thereby minimizing stray damage to other healthy tissues. It’s targeted; it preserves organ health; and it may reduce other harmful side effects.
The location of Ms. Cunningham’s tumor made the risk of blindness, memory loss and other grievous consequences particularly acute. However, at 54, she was neither young nor old. She fell in the age gap. No one has yet explained why that put her outside the range of coverage.
According to the Alliance for Proton Therapy Access, nearly two-thirds of cancer patients between the ages of 18 and 64 whose physicians recommend proton therapy as the best course of treatment for their disease are initially denied by their insurer. Patients and their physicians are sometimes successful in reversing the initial denial, but the delay averages nearly three weeks in the end. According to their report, proton therapy is denied more than four times out of ten, and it takes an average of more than five weeks for patients to receive that final denial.
The problem of coverage denials for treatments deemed “experimental or investigational” is not limited to proton beam cancer treatments, as patients who have sought coverage for other forms of modern medical treatment, including technologically advanced pacemakers or microprocessor-augmented prosthetic knees can testify. Many physicians reportedly
The denials may certainly add time and cost to a patient’s treatment, and the delay can affect the quality of outcome. Oranna Cunningham and her husband mortgaged their home to pay for proton beam treatment. She died shortly after receiving treatment anyway. There are apparently no allegations that a delay in treatment damaged her prognosis, but it might in other cases, especially in those where patients had no other financial recourse.
The jury’s award is fairly certain to be appealed for a variety of reasons. The most obvious of these is the size of the punitive damages portion.
Oklahoma’s tort reform law limits non-economic damages, including punitive damages, to $350,000. The cap can be waived where there is clear and convincing evidence of reckless disregard for the rights of others, gross negligence, fraud or malice. The attorneys for the Cunninghams will certainly argue this, but the result is uncertain.
In addition, they may argue that the lawsuit was brought as a contract dispute, not a tort case, since it involved the interpretation of an insurance policy. Counsel for Aetna will certainly counter with a policy argument about runaway jury verdicts, especially in situations where the plaintiffs are as likeable and sympathetic as the Cunninghams appear to have been.
Finally, of course, there is the question of whether Aetna’s denial of coverage, in fact, caused Ms. Cunningham’s death. She received proton therapy, which appeared at the time of her death to be shrinking the dangerous tumor at the base of her brain stem. She died of an infection. Whether the infection can be traced to the denial of coverage will be a matter of potentially difficult proof.
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