The Hartford has denied your long term disability claim. Can their decision be overturned? The answer: yes, it can — but you might want to get some help.
The Employee Retirement Income Security Act of 1974, or ERISA as it is more commonly known, is a federal law that was enacted by Congress to govern pension and insurance companies and protect the policyholders and plan participants. Among other things, ERISA allows policyholders to appeal an insurance company’s denial of benefits.
Marc Whitehead & Associates recently filed an ERISA lawsuit on behalf of a client in New York who suffered from Relapsing-Remitting Multiple Sclerosis. After paying long term disability benefits for over 3 years, The Hartford determined that she no longer met the Plan’s definition of disability and was no longer eligible for continued benefits.
The New York court where the suit was filed reviewed the administrative record and found that The Hartford had abused its discretion in denying our client’s claim.
The Hartford Wrongfully Denied Our Client Long Term Disability Claim
There were 3 ways in which The Hartford wrongfully denied our client’s Long Term Disability claim:
The Hartford ignored the Social Security Administration’s Favorable Decision.
After Hartford initially approved our client’s claim for long term disability benefits, she was encouraged to apply for Social Security benefits. With assistance from The Hartford, the Social Security Administration rendered a “fully favorable” decision and our client was awarded benefits. This means the SSA had determined that she was unable to perform work of any kind. Accordingly, Hartford applied an offset to her long term disability benefits as a result of her also receiving the SSDI benefits. However, when Hartford determined that our client was no longer eligible to receive benefits, it failed to give the SSA’s favorable decision any weight.
The Hartford Did Not Consider Contrary Medical Evidence regarding Multiple Sclerosis.
The Judge in the case acknowledged that, although The Hartford was not required to give special weight to the opinions of our client’s treating physicians, The Hartford was not permitted to rely on medical reports which support its denial of benefits without further investigation and consideration of more detailed reports which provide medical evidence to the contrary.
Our client had been treated by her neurologist just prior to Hartford’s denial of benefits. The neurologist’s report specifically documents the presence of “black holes” on her most recent Brain MRIs and in his opinion “all neurological experts attest” that their presence “correlated well with the degree of a patient’s disability.” The Hartford had two physicians conduct peer reviews of our client’s medical records; for some reason, both reviews failed to mention the documentation from the neurologist regarding the MRI findings.
The Court found that The Hartford’s decision to rely on the opinions of its peer review physicians was arbitrary and capricious due to the fact that our client’s neurologist discussed an important finding that was significant to her limitations and her disability which Hartford’s peer review physician entirely failed to address. The Hartford should have conducted further investigation regarding the MRI findings and the effects of the “black holes” on our client’s functionality.
The Hartford Was Wrong To Rely On Surveillance Video.
While The Hartford was paying our client her continued long term disability benefits, it conducted yearly reviews of her claim to determine her continued eligibility for benefits. During the last review, our client gave information to Hartford that she was not able to perform some daily activities and that she required assistance from her husband and mother. In contrast, her neurologist informed The Hartford that she did not require assistance to perform daily activities. In an effort to sort out this discrepancy, Hartford conducted video surveillance of the client to determine what activities she was actually capable of performing.
The Court found that Hartford heavily relied on the surveillance video when making its determination to deny benefits. Relapsing-Remitting Multiple Sclerosis, as the name suggests, is a disease whose symptoms fluctuate over time. The Court stated that the video surveillance did not contradict her statement that she was not able to sit for most of a workday, nor did the video show that she was able to perform work-related tasks, such as sitting, standing or walking, for 8 hours per day, 40 hours per week.
Our Client Was Right To Appeal The Hartford’s Decision
Based on these three reasons, The Court ruled that The Hartford’s determination that the client’s condition has improved such that she was no longer disabled from performing full-time sedentary work was incorrect. The Court granted our client’s motion for summary judgment and awarded her benefits and attorney’s fees, with judgment withheld until the amount of benefits due was determined.
Marc Whitehead & Associates have successfully handled long term disability claims appeals involving The Hartford and other major insurance companies for over 25 years. If you believe your insurance company is unfairly denying or delaying the disability benefits you deserve and have paid for, we’re here to help. Contact the law offices of Marc Whitehead & Associates at 866-365-7898 to speak with an experienced disability benefits attorney to discuss your particular disability insurance issue.
Be sure to download a copy of our free e-book: Disability Insurance Policies, How to Unravel the Mystery and Prove Your Claim.