Denial of Long Term Disability claim based on an incomplete review of the medical record.
Margaret C., M.D. (The Hartford)
At the time her claim arose, Margaret was a 45-year old radiologist, employed by a very well-known hospital. She had a 35-year history of scoliosis. However, this condition did not cause any disability or otherwise affect her ability to work, until she delivered her first child. She originally left work, on maternity leave, with the intention returning to work, after the birth of her child; however, following the delivery she experienced severe, disabling back pain, as a result of which she was not able to work. She did return to work on a trial basis, working part time, but found that she was unable to perform the assigned duties of her job, even working part time. Margaret left work altogether and was not able to return. X-Rays revealed degeneration of discs of the lumbar spine.
Margaret’s LTD Policy provided a very high grade of coverage, which was to pay benefits to age 65, so long as she met the definition of “Disability”, which was as follows: "Total Disability means you are prevented by Disability from doing the material and substantial duties of your own occupation and are not earning more than 20% of your Pre-disability Earnings. If you are a Physician, Dentist or Attorney, your 'own occupation' means your specialty in the practice of medicine, dentistry or law."
The evidence clearly showed that the occupation of a diagnostic radiologist is not a sedentary-type job. It requires a substantial amount of sitting, standing, bending, twisting, working with patients, taking call and wearing heavy lead aprons for radiation protection. The job involves handling, lifting, and carrying radiology files, which can weigh between 2 to 15 pounds. The medical evidence very clearly established that Margaret could not physically perform the material duties of her own occupation.
Margaret submitted a claim for Long Term Disability benefits. The Hartford had its in-house "Medical Director" conduct a paper review of the file. The reviewer focused on the history of scoliosis, finding no change in her condition, while ignoring the radiological evidence of degenerative disc disease and concluded, “It is my belief that (Margaret) has the physical capacity to perform the full material duties of a diagnostic radiologist.” The initial denial letter from The Harford, was based primarily on the Medical Director’s report.
I submitted an ERISA administrative appeal on Margaret's behalf.
Result: The case was resolved administratively, without the need for litigation. All benefit payments were resumed.