Long Term Disability claim denied based on a one and a half page paper review.

In Re: Jane Doe

[Confidentiality provision of a settlement agreement prohibits disclosure of identity of parties].

Ms. Doe was in her early-50s, when she became disabled. She had worked for a major bank, as a Senior Account Executive., which required that she typically work 6 to 7 days a week. Her workday generally stated at about 7:00 A.M, continuing until 11:00 P.M. or 12:00 midnight. She often worked 18 to 20 hours a day.

While working, she fell down in a parking lot. She apparently slipped on loose gravel, while getting out of her car. She turned, lost her balance, and landed on her left hip and left outstretched hand. She had no history of back pain prior to the fall. Her fall was precipitated in part by the fact that she tried to save a bank-owned laptop computer from hitting the pavement after she slipped.

After the accident, she did return to work, but after 8 months of struggling in pain, she found she was unable to perform the duties of her job. She was diagnosed with severe left sciatica and S1 Joint Dysfunction, which left her totally disabled from work. She left work, on advice of her doctor and was never able to return.

Before she hired me, she called an insurance company "Case Management Specialist", who told her that her medical records looked very complete and that he did not see any problem with her receiving Long Term Disability benefits. He said that the only two things he needed for final approval were information that he had requested from her employer and a review of the file to be completed by the insurer’s nurse practitioner.

But when she spoke to that same person about two weeks later, everything had changed. At that time she was told that her LTD claim would be denied, based upon a review by the insurance company’s paper-review doctor, who concluded that her medical reports did not warrant any disability payment. She asked this Case Management Specialist how it could be that the insurer’s medical reviewer had approved her short-term disability claim (STD), and yet the insurer suddenly reversed itself when it came to her LTD claim. She was told that her STD claim was approved because her employer was responsible for paying it, but that her LTD claim was denied because the insurer was responsible for paying it.

The medical evidence in support of Ms. Doe’s ERISA-governed Long Term Disability claim was clear. And yet, the insurer denied her claim, based on a one and a half page "Physician Consultant Review" report, which concluded that she was capable of sedentary work.

Result: The case was resolved satisfactorily.

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