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Long Term Disability Insurance Fraud

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Policyholders purchase long-term disability insurance to protect themselves in the event they become disabled and can no longer carry out their job duties. Unfortunately, some long-term disability (LTD) policyholders have their disability claims improperly denied. Policyholders who have their long-term disability claim denied can appeal the decision, but should speak with an attorney first, to ensure their rights are protected throughout the process.



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Long-Term Disability

ltdsupercasepageLong-term disability is supposed to protect policyholders in case they become sick, injured, or otherwise disabled for an extended period of time and are no longer able to carry out their work-related duties. When that happens, policyholders file a long-term disability claim to have their benefits begin. Long-term disability plans often begin to provide benefits after a policyholder has been unable for work for six months, and the LTD plans typically pay about 60-80% of the policyholder's pre-disability earnings. LTD plans differ according to the terms of the plan, so each individual's plan needs to be reviewed accordingly. Unfortunately, some long-term disability claimants find that their claim is denied or is originally approved only to be terminated later.
 

Long-Term Disability and ERISA

Often when long-term disability is discussed, it is mentioned alongside "ERISA." ERISA, the acronym for "Employee Retirement Income Security Act," is a federal law that was put in place to protect workers' pension plans. ERISA was expanded to also apply to employer-provided long-term disability plans. If you've purchased a long-term disability insurance plan on your own--i.e., not through your employer benefits plan--then ERISA law typically does not apply; state law governs individual long-term disability insurance plans.

Because of this, it is best to seek the assistance of a long-term disability attorney to help guide you through any issues you might face as you file your disability claim. Also, while ERISA laws were enacted to protect workers' rights, unfortunately, ERISA is known to favor the insurance companies.
 

Long-Term Disability Lawsuit

manwearingneckbraceDepending on the policyholder's circumstances, the policyholder may have to file an appeal before filing a lawsuit. If the disability insurance is purchased through an employer, the insurance is governed by ERISA. In such cases, any denials must first be appealed with the insurer. The appeals process must be exhausted before a lawsuit can be filed.

The administrative appeal, however, involves a great deal of paperwork, and you may be required to file one or more of these appeals. The paperwork filed in support of the appeal will be the only evidence considered for both the appeal and—if the appeal is denied—the lawsuit. All evidence—including medical records, expert opinions, and other supporting documentation—must be included in the administrative appeal or it will not be considered by the judge in a subsequent lawsuit.

If your long-term disability claim has been denied, you should first request a complete copy of your claims file from the plan administrator. Through ERISA, your insurance company is required to provide you with a copy of your claim file at no cost. This information is important to have in order for you to be able to identify and include additional evidence in your claim file. While the administrative appeal(s) needs to be exhausted according to ERISA, it is still wise to speak with a long-term disability lawyer to ensure you are following the LTD claim appeal process correctly, meeting your deadline dates, and adding as much supportive evidence to your claim file as possible.

Note, if the insurance is purchased directly by the policyholder, and not obtained through an employer's benefits plan, the policyholder can file a lawsuit without filing an appeal of the denial.

Policyholders have their insurance claims denied for many reasons. Sometimes the insurance company does not have an accurate picture of the claimant's work duties and believes the claimant can go back work. The insurance company might also claim that the policyholder is not as disabled as he or she claims, or that the claimed disability is not covered by the policy (this is sometimes the case with conditions such as fibromyalgia).

In other cases, insurance companies may claim not to have received important documentation or not received information from policyholder's medical care provider. Or the insurance company might claim the injury is pre-existing, there is no objective medical evidence for the claim, or that there is no injury at all.

One of the most common long-term disability denials, however, happens when the insurer claims that the LTD claim was filed too late. It is of utmost importance to ensure all key filing dates are met when filing your LTD claim.
 

Bad Faith Insurance

Insurance companies are required to pay claims in good faith—meaning the claims must be paid willingly, promptly, and properly. All denials must be made for legitimate reasons. When companies deny insurance claims for invalid reasons—such as to make quotas or protect profits—or otherwise breach their covenant of good faith and fair dealing, they are committing bad faith insurance.

Bad faith insurance can also involve failing to promptly pay or investigate an insurance claim, not properly disclosing policy benefits, or failing to provide benefits as written in the insurance policy.
 

Long-Term Disability Companies

All insurance companies have a claims procedure and have legitimate reasons for denying long-term disability claims.

Among the long-term disability insurance companies are:
 
  • Unum (previously called Unum Provident and First Unum), has faced lawsuits alleging improperly denying legitimate claims;
  • Aetna;
  • Cigna, which in 2013 reached a regulatory settlement with five states who alleged the company was improperly handling claims;
  • AIG;
  • Allstate;
  • Colonial Life & Accident Insurance Company;
  • The Guardian Life Insurance Company of America;
  • Liberty Mutual
  • John Hancock Life Insurance Company;
  • New York Life Insurance Company;
  • MetLife (Metropolitan Life Insurance Company;
  • Prudential;
  • Penn Mutual.
 

Long-Term Disability Insurance

Just because an insurance company denies a claim for long-term disability insurance doesn't mean the policyholder has an invalid claim. There are many reasons for denying a claim that go beyond the legitimacy of the illness or injury. When claims are denied, policyholders have a right to have that decision reviewed. An experienced attorney can help with the insurance claims process, which can be long and complicated.
 

Register your Long Term Care Disability Insurance Complaint

If you have had a long term disability insurance policy falsely represented to you, or been denied a long term care disability insurance claim, you may qualify for damages or remedies that may be awarded in a long term disability fraud insurance lawsuit. Please click the link below to submit your complaint to an insurance lawyer for a free evaluation.

 


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LTD INSURANCE FRAUD LAWSUITS


LTD INSURANCE FRAUD LEGAL ARTICLES AND INTERVIEWS

LTD Claimants Win Big as Ninth Circuit Trims “Abuse of Discretion” Standard
LTD Claimants Win Big as Ninth Circuit Trims “Abuse of Discretion” Standard
January 11, 2019
San Francisco, CA In one of the earliest decisions of 2019, the Ninth Circuit gave plaintiffs in long term denied disability lawsuits a new way to challenge benefit denial decisions. It may turn out to be significant.
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Unum Disability Insurance Claimant Wins Reinstatement of LTD Benefits
Unum Disability Insurance Claimant Wins Reinstatement of LTD Benefits
January 8, 2019
Santa Ana, CA On November 20, 2018, the U.S. District Court for the Central District of California handed Pamela Fleming a resounding victory in her Unum disability insurance lawsuit. Unum had been paying her LTD benefits since 2005, after a serious and well-documented neck injury sustained in a car accident. A change in her treating physician and a brief surveillance video led the insurer to re-evaluate her claim and declare that she had recovered. The insurer terminated her benefits. Judge Cormac J. Carney was not impressed and reinstated her benefits due under the policy.
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Jury Awards $25.6 Million in Bad Faith Insurance Lawsuit
Jury Awards $25.6 Million in Bad Faith Insurance Lawsuit
December 17, 2018

Oklahoma City, OK In November 2018, a jury awarded nearly $25.6 million to the family of a Oranna Cunningham, a woman who was diagnosed with advanced nasopharyngeal cancer. Her insurer, Aetna, refused to cover the cost of the proton beam therapy recommended by her physician, claiming that it was “experimental or investigational.” After her death, her husband brought a 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 feel strongly that “experimental or investigational” denials are often a sham.


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.

Challenges Ahead




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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READER COMMENTS

Posted by

on
I have a hep c and also have seizures been in and outta jail for the beginning of my 18s to end of 24. so I try and work but just don't have the knowledge and my record from past. mistakes keeps me out of a lot of places I'd like to work but no one helps.i can't believe I didn't get disability I've been to rehab over 10 times I'm not good at getting a job because most people see my record and Bang I'm out the door. Gavin this problem I deal with everyday .makes it hard to keep tryna find work with all this baggage . could yall help

Posted by

on
Lincoln Financial Group is asking me to pay them almost 35k back. I know that is not what I sign up for, but when they stopped paying me over a year ago and left me without any income I figured we were done. I'm pretty sure I threw away all related paperwork since I had not heard from them in over a year. Now I think I'll be needing a lawyer.?

Posted by

on
I was denied ltd because principal insurance is a corrupt and horrible company i hope there is a class action lawsuit against them real soon

Posted by

on
Was told that because I went out on long term disability in 2009 that I would recieve payments until my retirement year. I was also tokld that my payment after getting Socia security disability that I would those payments and the long term insurance if I was permanently disabled up to the amount of my established long term payment until I retired as soon as I got social security they started sending monthlyrequired paperwork late and requested I pay back all disability they had given me? I know I was on serious meds because of my injuries but it felt scammy!

Posted by

on
Pleasrycall me I have much to say about this corrupt company, I would love to speak with thr media, as well as the EEOC, ERISA, the Federalelabor Board. Bring it on or are you scared. Have your Numbers with you because I will have mind!

Posted by

on
I have paid for long term disability through my employer for 21 years.I became disabled under UNUM guidelines and had been receiving payments. They suggest I file for SS benefits. They said it would lower their payment to make up the difference I receive from SS and what I was receiving for LYD. My SS claim was approved and had been handled by Genix. My case was approved and I received payment from SS as back payment for my application date. Unum is saying I have to pay them back for the back payments. SS's letter states the check is being issued to me and not a 3rd party. Do I have to give the UNUM company all of the back payment money I received from SS? Thank you.

Posted by

on
That sounds so much like me. I experienced a very similar situation where the Standard Insurance company denied my claim because I tried to return to work. I never got approved for the Ltd which I was forced to have and to pay for. It's terrible that on top of his illness, the pathetic system fought against paying him.

Posted by

on
I have been in two vehicle accidents and have had back surgery, resulting in chronic pain, failed back syndrome after surgery, spondylosis, degenerative joint disease, bulging discs, etc.... All physicians I have seen said I was unable to work. I have lost everything because I'm caught between 'them' and 'us'. I have since remarried and moved to the UK. I have a person who is supposedly working on this, however it's been months. I tried handling it all on my own but got nowhere. I appealed through Prudential and never received a reply!

Posted by

on
I receive social security and was getting pension from GE. And they sent a letter informing me it was in error. I have a copy of the terms and do not see where this is. I have sent a certified letter and still no reply.

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