Check out the disability success stories below and browse our client reviews and video testimonials to help you decide if the Ortiz Law Firm is the right choice to help you recover the disability benefits you deserve.
The following are just a sample of some of the long-term disability insurance claims we have brought to a favorable resolution. Names have been withheld to protect our client’s privacy.
New York Life and Cigna
New York Life Group Benefit Solutions Approves Claim for Pudendal Neuralgia and Chronic Regional Pain Syndrome on Appeal
This claimant contacted our office after she received notice that New York Life Group Benefit Solutions (NYL GBS) had denied her appeal and upheld the denial of her short-term disability benefits. The claimant was a 36-year-old registered nurse care coordinator who suffered from pudendal neuralgia and chronic regional pain syndrome. We assisted the claimant in submitting a second STD appeal and an application for long-term disability benefits.
We continued to provide additional evidence throughout the claim/appeal review, but NYL GBS still needed an independent physician consultant (IPC) to review the claim. The results of this review were unfavorable, so NYL GBS upheld its denial of the STD claim and denied the newly filed LTD claim. This was the final administrative denial in the STD claim, but we still had the opportunity to appeal the LTD claim denial.
We appealed the LTD denial and disputed the findings of the IPC review. Finally, NYL GBS determined that it should overturn its prior decisions to deny both the STD and LTD claims, and the claimant received the benefits she deserved.
New York Life Group Benefit Solutions Approves LTD Claims for Disabled Veteran
In this case, the claimant contacted our office after he received notice that New York Life Group Benefit Solutions (NYL GBS) had denied his appeal and upheld the denial of his short-term disability benefits. The claimant was a veteran in his 60s who was suffering from PTSD, Meniere’s disease, migraines, herniated discs, and several other conditions that contributed to his inability to work.
We assisted the claimant in submitting a claim for long-term disability benefits. New York Life also denied the long-term disability insurance claim. We appealed the LTD denial, which prompted NYL GBS to order an independent medical evaluation. NYL GBS finally determined that the prior decision to deny LTD benefits should be overturned, and LTD benefits were paid.
New York Life Overturns Termination of “Any Occupation” Claim for Intake Specialist
This claim was originally approved under the “own occupation” definition of disability. To determine if the claimant could perform “any occupation,” New York Life sent the claimant for an independent medical examination (IME) and sent the file to a vocational rehabilitation specialist for a transferrable skills analysis.
The IME concluded that the claimant had a sedentary residual functional capacity (the ability to do a “desk job”), and the transferable skills analysis concluded that the claimant could perform sedentary occupations. As such, New York Life determined that the claimant no longer satisfied the definition of disability and closed the claim.
We appealed the decision to terminate the claimant’s benefits. During the review of the appeal, New York Life ordered two peer review reports (paper file reviews by their doctors) and an additional transferable skills analysis. Not surprisingly, these reports supported New York Life’s termination of benefits.
We were allowed to comment on the reports before the decision was finalized. We disputed the findings, arguing that the greater weight of evidence demonstrates that the claimant cannot perform work activity of any kind. New York Life agreed with us, overturned the prior denial, and reinstated the claim!
New York Life Reinstates Benefits for Medical Billing and Collections Specialist
Ten weeks after initially approving this short-term disability claim, New York Life conducted a nurse case manager (NCM) review and terminated benefits based on the NCM’s report.
In the notice of termination, New York Life stated, “We do not dispute you may have been limited or restricted due to your diagnoses; however, an explanation of your functionality and how your functional capacity prevented you from performing your occupation was not provided. Current medical information does not support restrictions of no work. Your claim has been closed, and no benefits are payable.”
We appealed this wrongful termination of benefits and initiated a claim for long-term disability benefits. During the appeal review, New York Life conducted a medical review and concluded that a continued denial was warranted.
We argued that the claimant’s conditions, including pain and mental health issues, cause issues that would lead her to be “off task” frequently, which would preclude competitive employment. We further argued that the medical reviewer failed to consider that the claimant’s medication side effects impair her abilities and that pain limits the claimant’s sleep, which also has an effect on her mood and emotional status.
Our appeal was successful! New York Life not only overturned their previous STD claim denial but also approved the claimant’s LTD claim.
Long-Term Disability Benefits Reinstated for Senior Internal Mail Specialist with Navy Federal Credit Union Suffering from Bi-Polar Disorder
The claimant received all of her short-term disability (STD) benefits, but once the claim transitioned to long-term disability (LTD), New York Life Group Benefit Solutions (NYL GBS) denied the claim by ignoring inconvenient facts. We appealed the unjust denial, and NYL GBS overturned its prior decision to close the claim.
Long-Term Disability Benefits Reinstated for Radiologic Technologist Suffering from Crohn’s Disease
This claimant had been receiving benefits for over a year when Cigna terminated his claim based largely on the opinions of a nurse case manager and a medical director who never met or treated our client. Despite his diagnoses of Crohn’s disease, clostridium difficile, and severe postoperative complications, Cigna determined that he could meet the demands of his own occupation.
We filed an appeal that included medical assessment forms completed by two of the claimant’s treating physicians and additional medical evidence. Cigna ordered an independent peer review as part of the appeal review process. The review was favorable, and our client was promptly awarded benefits.
Senior Security Technician Suffering from Paralysis, Acute Transverse Myelitis, and Incontinence Approved for Long-Term Disability Benefits
While reviewing her claim for long-term disability benefits, Cigna ordered a transferable skills analysis (TSA). The TSA indicated that the claimant could perform two other occupations similar to her past work that would pay at least 60% of her pre-disability earnings. As such, Cigna denied the claim.
We obtained additional medical evidence and filed an appeal, and as part of the appeal review, Cigna ordered an independent medical examination (IME). Cigna concluded that our client could not return to a similar job and overturned the decision to deny her claim.
Successful Long-Term Disability Claim for Ultrasound Lead with Cubital Tunnel Syndrome and Other Upper Extremity Conditions
Our client was suffering from a wrist triangular fibrocartilage complex (TFCC) tear, wrist impaction syndrome, cubital tunnel syndrome, wrist extensor carpi ulnaris (ECU) tendonitis, weakness in her left hand and wrist, tingling and numbness, and wrist pain and tenderness.
While reviewing her claim for benefits, Cigna ordered a medical file review. However, the review doctor determined that the objective findings in the medical records were inconsistent with her subjective complaints despite never having treated our client. Cigna denied the claim based on this report. We submitted an appeal with additional medical evidence and a statement from her doctor, and the denial was promptly overturned.
Long-Term Disability Benefits Reinstated for Telehealth Nurse with Spine Problems, Rheumatoid Arthritis, and Lupus
Cigna terminated our client’s claim for long-term disability benefits based on the opinions of an in-house physician advisor who indicated that she could return to work. We appealed the decision to terminate her claim, which prompted Cigna to order a peer review report, and the reviewing physician determined that the claimant could perform the duties of her occupation. As such, Cigna upheld the decision to terminate the claim.
We obtained a copy of the peer review report and provided it to the claimant’s treating provider, who then issued a statement disputing it. We included this statement and additional medical evidence with our second appeal, and Cigna overturned the prior decision to terminate the claim.
Long-Term Disability Benefits Reinstated for a Supply Chain Manager with Back and Neck Problems, Neuropathy, Sjogren’s Syndrome, and Cognitive Problems
This claimant received long-term disability benefits from Cigna for two years before the definition of disability changed from an “own occupation” to an “any occupation” definition.
We submitted an appeal, and Cigna ordered three independent medical reviews by different specialists, but each review indicated that the claimant could work. Cigna also ordered a transferable skills analysis and determined that the claimant could perform several occupations. Based on this evidence, the claim was denied.
As part of the second appeal, we obtained an independent vocational analysis from a local vocational expert who determined that the claimant could not perform sedentary work. Cigna ordered additional medical and vocational reviews indicating the claimant could not work, so Cigna overturned the previous decision to terminate her claim.
Operating Room Registered Nurse with Rectal Dysfunction, Proctitis, Bleeding, and Pain Approved for Long-Term Disability Benefits
Cigna denied this claim for long-term disability benefits based on the pre-existing condition limitation in her insurance policy; however, the pre-existing conditions for which she was treated were not the reason she went out of work.
We obtained additional medical evidence and statements from the claimant’s treating providers, which we included in our appeal, and we argued that Cigna failed to properly analyze and give credit to the claimant’s true disabled conditions. Several weeks later, the claim was approved.
Nurse with Chronic Regional Pain Syndrome/Reflex Sympathetic Dystrophy, Degenerative Disc Disease, Hashimoto’s Disease, Fibromyalgia, and Polyneuropathy Approved for Long-Term Disability Benefits
Our client received long-term disability benefits for 24 months, at which point the policy’s definition of disability changed from the inability to perform all the material duties of the claimant’s own occupation to the inability to perform the material duties of any occupation. Cigna identified several sedentary occupations that the claimant could perform, and her claim for benefits was terminated.
The claimant filed her own appeal, and Cigna ordered two peer reviews to clarify the severity of her impairments. Both peer-review physicians determined the evidence was insufficient to support the claim, and the denial was upheld.
Rather than filing a second appeal independently, the claimant contacted our office for assistance. We obtained additional medical evidence and statements from the claimant’s treating physicians, which we submitted with our appeal letter. Cigna ordered another peer review and vocational evaluation, but the documents supported the claim, and the decision to terminate the claim was overturned.
Patrol Deputy Suffering from Epilepsy Approved for Long-Term Disability Benefits
Our client received long-term disability benefits for 24 months, at which point the policy’s definition of disability changed from an inability to perform all the material duties of the claimant’s own occupation to any occupation. Cigna determined that the claimant could perform the duties of an information clerk or a civil service clerk despite his various limitations and terminated his claim.
The claimant filed his own appeal, and shortly thereafter, Cigna ordered several medical reviews and an independent medical examination (IME) with a Board Certified Neuropsychologist, but the evidence obtained supported Cigna’s termination of the claim, so the decision was upheld. At this point, the claimant contacted our office to file his second appeal. We submitted new evidence from the claimant’s treating physicians that contradicted the evidence obtained by Cigna, and the claim was reinstated.
Lincoln and Liberty Mutual
Senior Analytics Consultant Approved for Short-Term and Long-Term Disability Benefits
Lincoln terminated this short-term disability claim after just 11 weeks. The claimant initially filed her own appeal but then hired the Ortiz Law Firm to assist her with the appeal process. Although Lincoln would not delay its consideration of the appeal so we could completely redo it, we could obtain and submit additional records supporting it until Lincoln decided the claim. Because the claimant’s disability had extended beyond the maximum STD benefit period, we also requested that Lincoln open an LTD claim.
Lincoln denied both the STD appeal and the LTD claim. We could not appeal the STD denial, as it was the final administrative denial, but we could appeal the LTD denial. Despite the STD denial being upheld, we received notification that the decision to deny the LTD claim had been overturned! Since the LTD claim had been approved for the same conditions the STD claim had been denied, we asked that Lincoln reconsider the denial of the STD claim to avoid the expense of litigation. Soon after, we received notice that the STD denial was also overturned!
Lincoln Overturns Termination of “Any Occupation” Claim for Truck Driver
This claimant received benefits for lumbar spine problems for a period of 11 months, at which point Lincoln Financial initiated a review of the claim for the change in the definition of disability from “own occupation” to “any occupation.”
To evaluate the severity of the claimant’s impairment, the file was referred for review by a consulting physician who determined that there were no impairing diagnoses and no documentation to support impairment. The insurance company acknowledged that the claimant continued to “experience some symptoms.” However, the insurance company then opined that the medical records on file did not support an impairment that would preclude the claimant from being able to return to work at “any gainful occupation.”
We appealed the wrongful termination of benefits, disputing Lincoln’s decision with the argument that there is a big difference between an in-person and “on paper” medical review and that Lincoln cannot ignore the claimant’s subjective symptoms and use of pain medication. A mere 30 days after we submitted our appeal, Lincoln completed its appeal review and overturned the prior decision to close the claim.
Short and Long-Term Disability Benefits Approved for Customer Service Representative with Back Problems
The claimant first came to us for help with her short-term disability claim. Lincoln denied the claim because it had determined the medical records provided in support of the claim did not support restrictions and limitations that would render our client unable to perform the main duties of her own occupation. We appealed this decision, and the STD denial was overturned. The claimant was also partially approved for long-term disability.
Lincoln initially approved this claim for a limited period because there were no “findings on physical examination or testing that would indicate specific restrictions and limitations.” However, the policy did not require objective medical proof. We appealed, and the decision to terminate the claimant’s long-term disability benefits was also overturned.
Long-Term Disability Benefits Reinstated for Senior Sales Specialist Suffering from Status Post Stroke, Polyneuropathy, and a Left Leg Amputation
Liberty Mutual (the branded name for Liberty Life Assurance Company of Boston) paid disability benefits for more than two years, then terminated this claim following an internal vocational analysis, which concluded that she could purportedly perform the duties of several other occupations based on her capacity and skill level.
We obtained additional medical evidence and argued that Liberty Mutual failed to analyze vocational factors that prevent her from performing the duties of any occupation. Liberty Mutual completed its review and reinstated the claim.
Long-Term Disability Benefits Reinstated for Backroom Receiver Suffering from Back Problems, Neuropathy, Fatigue, and Depression
Our client was suffering from hand pain, back pain, spinal stenosis, neuropathy, chronic fatigue, diabetes, and depression and had only received two months of benefits when Liberty Life referred her claim for clinical review by a Board Certified Psychiatrist and a Board Certified Neurologist. Based on these clinical reviews, Liberty Life determined that the claimant no longer met the definition of disability as defined by the policy, and her benefits were terminated.
We submitted an appeal with the claimant’s sworn statement, a statement from the claimant’s treating physician, and the claimant’s updated medical records. Upon review of the appeal, Liberty Life overturned the previous decision to terminate her claim.
Successful Long-Term Disability Appeal for Senior Pharmaceutical Materials Specialist Suffering from Spinal Stenosis, Chronic Back Pain, and Lumbar Degenerative Disc Disease
Liberty Life paid our client’s long-term disability benefits for nearly two years before terminating the claim based on the opinion of one independent physician who never treated him or even spoke to his treating physician. The independent physician noted that subjective complaints alone do not meet the qualification for restrictions, and the available medical records do not indicate the severity of symptoms that would prevent full-time work without restrictions.
We obtained updated medical records and statements from the claimant’s treating physicians, which contained vast amounts of medical evidence detailing his severe limitations and restrictions. Shortly after we submitted the appeal, Liberty Life reinstated his claim.
Reliance Standard
Reliance Standard Reinstates Benefits for a Claimant with Fibromyalgia and Chronic Pain
This claim was approved for benefits under the “any occupation” definition of disability, but after nearly eight years, Reliance Standard performed a full file review with a vocational rehabilitation specialist. After its review, RSLI concluded that the information available purportedly did not support an inability to perform “any occupation.” In other words, RSLI felt the claimant could work.
We appealed this decision, which prompted Reliance Standard to order a peer review report (PRR) and transferrable skills analysis to evaluate the claim further. Not surprisingly, the reports by the experts hired by Reliance Standard supported the decision to terminate benefits.
We argued that the PRR doctor ignored the importance of the claimant needing “frequent unscheduled breaks.” We also pointed out that Reliance Standard’s vocational specialist had determined the claimant could perform a sedentary occupation – the same type of occupation the claimant had before, which the claimant could no longer perform due to the claimant’s conditions. Soon after, we received notice that Reliance Standard had determined that its original decision to terminate the claim should be reversed and that the claimant’s benefits would be reinstated.
Service Desk Analyst Suffering from Anxiety, Depression, Headaches, and Chronic Pain and Fatigue Approved for Long-Term Disability
Reliance Standard denied our client’s claim for long-term disability benefits because he had recently been terminated and was no longer a member of the eligible class of employees. We appealed the denial and argued that the claimant’s disability began before his termination – and while he was still a participant in the program – such that he was eligible for benefits. Reliance then ordered an independent medical examination (IME), and less than one month later, the denial was overturned.
The claimant continued to receive benefits due to his severe anxiety and depression up to December 16, 2017, at which point the benefits were terminated due to a policy provision that limits payment of benefits for disability caused by or contributed to by a mental or nervous disorder to 24 months. We appealed this decision, and Reliance Standard ordered an additional IME, which determined that the claimant was disabled due to frequent headaches, chronic neck and back pain, and chronic fatigue.
Long-Term Disability Benefits Reinstated for Service Agent Suffering from Post-Stroke Symptoms, Diabetes, Headaches, and Heart Disease
This claimant received long-term disability benefits from Reliance Standard for two years, at which point the definition of disability changed, and the claimant had to prove that she could not perform any occupation. Reliance ordered a neuropsychological evaluation, determined that the claimant was able to perform sedentary work, and her claim was terminated.
Our firm filed an appeal on behalf of the claimant. Reliance ordered an independent medical examination with a doctor specializing in physical medicine and rehabilitation, and shortly thereafter, the decision to terminate the claim was overturned.
Prudential
Successful Long-Term Disability Claim for Registered Nurse with Migraine Headaches
Prudential denied this claim after an internal file reviewer determined that no objective findings were documented to warrant any medically necessary restrictions or limitations from working as a registered nurse and because the claimant’s complaints were solely based on self-report.
We provided updated medical evidence with our appeal. One of the claimant’s treating physicians advised Prudential that the claimant could not work; however, a senior appeals analyst upheld the decision to deny the claim. We filed an additional appeal, and Prudential had the claim reviewed by two independent physicians. Based on the independent reviews and the medical evidence we submitted with our second appeal, Prudential determined that the claimant was eligible for benefits and reinstated the claim.
Successful Long-Term Disability Claim for Client Service Administrator with Major Depression, PTSD, Anxiety, and Insomnia
Prudential denied this claim by “cherry-picking” the medical evidence for damaging evidence. The claimant appealed, and Prudential ordered an external file review with a board-certified psychiatrist, who agreed that no medically necessary restrictions would prevent the claimant from performing the duties of his occupation.
We filed a second appeal, and Prudential ordered an independent medical evaluation (IME). The insurance company determined that the claimant was eligible for benefits based on the IME report and the medical evidence we submitted on appeal.
The Hartford and Aetna
The Hartford Overturns Claim Denial for Senior Office Administrator
This claimant applied for short-term disability benefits due to lupus, arthritis, ulcerative colitis, and neurological issues. While reviewing the claim, Hartford determined that there were no objective findings to support disability from performing the claimant’s own occupation.
More specifically, Hartford claimed the information initially provided was insufficient to support that the claimant was operating at a “less than sedentary” capacity. The claimant also applied for long-term disability benefits, but Hartford denied that claim because the claimant had supposedly not met the elimination period.
We appealed the STD denial and provided additional medical evidence. Soon after, Hartford overturned its prior decision to terminate the claim. We then appealed the LTD denial, arguing that since Hartford had since approved the STD claim through the maximum benefit period, Hartford should also approve the LTD claim. Hartford agreed and approved the claimant’s LTD claim.
Mental Health Claim with The Hartford Approved on Appeal
Hartford initially denied the claimant’s short-term and long-term disability claims because it supposedly had not received all the necessary information to evaluate whether the claimant was eligible for benefits.
The STD appeal deadline was approaching, so we submitted an abbreviated appeal and requested that the insurance company toll the claim until we could obtain and review the complete claim file and insurance policy.
We obtained all the information we needed, submitted all our supporting evidence, and notified Hartford that the STD appeal was complete and ready for review.
Hartford ordered two independent medical record reviews – internal medicine and psychology reviews. We disputed the findings of these reviews and argued that more evidence supported the disability claim.
Hartford continued with its STD appeal review, and it was during this time that we submitted the claimant’s LTD appeal. Less than one month later, we received notice that Hartford had approved both the STD and LTD claims.
Hartford Reinstates “Any Occupation” Claim
A claimant with complex regional pain syndrome, rheumatoid arthritis, and fibromyalgia – with symptoms including migraine headaches and chronic pain in the neck, back, tailbone, legs, feet, and hands – had been receiving benefits for two years when the definition of disability changed from “own occupation” to “any occupation.”
Hartford identified potential sedentary occupations that the claimant purportedly could perform and terminated benefits, concluding “that you are not prevented from performing the essential duties of any occupation.” We appealed the termination and successfully argued that the surveillance video, which showed the claimant participating in a community service program, did not mean she could work a full-time, sedentary position. Hartford agreed and overturned its previous decision to terminate benefits.
Denial Overturned for Truck Driver with Cardiac Conditions
Hartford initially approved this claim due to the claimant’s inability to perform one or more of the essential duties of his own occupation as a local commercial truck driver with O’Reilly Automotive, Inc. due to cardiac conditions. He received benefits for a time, but his benefits were terminated when Hartford claimed that the claimant did not fully participate in the rehabilitation program because Hartford’s vocational rehabilitation counselor reported that they purportedly made multiple attempts to contact the claimant to complete the process and had been unsuccessful.
That assertion was false, as the claimant’s physician had not released him to attend. We appealed the decision to terminate benefits, and Hartford had its own physician review the claim. The reviewing physician determined that the claimant could work a sedentary occupation, but we argued that the reviewing physician’s report supported the claimant’s claim. Because the claimant’s “own occupation” was a medium-duty occupation and the peer review report identified a maximum capacity for sedentary work, the claimant satisfied the definition of “disability” under the policy. We requested that benefits be reinstated immediately. Hartford overturned the previous denial and reinstated the claim.
Long-Term Disability Claim Approved for Registered Nurse with Borderline Personality Disorder, PTSD, and Chronic Pain
Hartford’s decision to deny this claim was based largely on an independent psychiatric peer review, which indicated that the claimant was purportedly able to perform her own occupation despite the reviewer having never treated or met our client.
We obtained additional medical evidence and filed an appeal in which we argued that the claimant’s own treating providers had detailed her severe psychiatric impairments. Hartford ordered an independent medical review, and the reviewer determined that due to a combination of medical conditions, the claimant could not work full-time, and her claim was approved.
Successful Long-Term Disability Appeal for System Administrator Suffering from Post-Concussion Syndrome
Hartford terminated this claim for long-term disability benefits after reviewing the medical information in the file and conducting an occupational analysis. We filed an appeal and submitted new medical evidence, a statement from the claimant’s doctor, and statements from the claimant and his wife. Hartford completed their appeal review, and our client was promptly awarded benefits.
Successful Long-Term Disability Appeal for Nutrition Service Supervisor Suffering from Osteoarthritis and a Left Knee Replacement
Aetna terminated our client’s claim for long-term disability benefits after the definition of disability changed from the “own occupation” standard, and the claimant had to prove that she could not perform “any occupation.”
We filed an appeal, and Aetna invoked their right to an extension so they would have an opportunity to order peer reviews and conduct peer-to-peer contact with the claimant’s treating providers. Her claim was soon reinstated.
Long-Term Disability Benefits Approved for Dietician with Myasthenia Gravis
This claim was initially approved, but then Hartford ordered a peer review. The peer review physician determined that the claimant was no longer impaired, and the claim was terminated.
We appealed the wrongful termination of benefits. In addition to the claimant’s medical records, we also obtained a statement from her treating physician contradicting the findings of the peer review physician. Less than a month later, we received notice that the long-term disability claim had been overturned.
The Standard
Successful Long-Term Disability Appeal for Estimator/Project Manager with Osteoarthritis
After receiving disability benefits for nearly three years, Standard Disability Insurance Company reviewed the claim and determined that the claimant was no longer eligible for benefits. The Standard obtained a physician consultant review, indicating the claimant could work in a medium-level capacity. We obtained evidence contradicting the third-party review, filed an appeal, and Standard reinstated the claim.
MetLife
MetLife Improperly Terminated Senior Vice President’s Claim After 24 Months
MetLife initially approved a claimant to receive long-term disability benefits due to mental health impairments. After 24 months of paying benefits, MetLife reviewed the claim and determined that the evidence purportedly did not support further restrictions or limitations.
This MetLife plan, like many Metropolitan Life long-term disability plans these days, has a provision that states:
“Monthly Benefits are limited to 24 months during your lifetime if you are Disabled due to a Mental or Nervous Disorder or Disease, unless the Disability results from schizophrenia, bipolar disorder, dementia, or is organic brain disease.”
So, there are exceptions to the 24-month limitation for mental health impairments.
The claimant provided evidence indicating a diagnosis of a covered medical condition exception. However, per the denial letter, MetLife required “objective” medical proof of the covered medical condition, which is not the burden of proof required by the plan.
We appealed the denial, arguing that it is inappropriate for MetLife to dismiss the claimant’s treating medical providers’ specific diagnosis of covered medical condition exception and that the diagnosis extended the claimant’s benefits beyond the 24-month mental health limitation period. Just a couple of weeks later, the claim was reinstated.
MetLife Overturns “Any Occupation” Denial for Registered Nurse
This claim was originally approved under the “own occupation” definition of disability, but as the claim approached the “any occupation” period, MetLife conducted a review to determine if benefits would still be payable. MetLife ordered an independent physician consultant (IPC) review and a transferrable skills analysis, concluding that the claimant could perform other occupations. As stated in the termination letter,
“Because alternate occupations were identified, that you could perform with the current supported restrictions, and that would provide you with a gainful wage, you no longer meet the policy definition of disability after the change in definition and your claim will be terminated.”
During the appeal process, MetLife ordered an additional IPC review, an employability assessment, and a labor market analysis, which identified other occupations the claimant could perform. However, we argued that the reviewing doctor ignored the treating physicians’ opinions and assigned his own restrictions. Therefore, the employability assessment and labor market analysis update was unsupported, as it was based on the reviewing physician’s restrictions rather than those from the treating provider.
We also argued that MetLife failed to consider cognitive impairments. Due to the claimant’s chronic pain, medications, and insomnia, she would be off task at least 10% of the time and would require at least three unscheduled breaks per day to prevent impaired attention, concentration, and processing speed. As such, the claimant cannot perform the identified occupations from a cognitive aspect, and the claim should be reinstated.
MetLife then ordered an addendum to the IPC review. The reviewing physician held firm that his opinions outweighed those of the treating physician and the claimant’s subjective complaints. We countered with the argument that the physician did a “paper” peer review and not an “in-person” medical examination, which raises questions about the thoroughness and accuracy of the determination. Finally, we received notification that MetLife had completed its review of the appeal and reversed its original decision to terminate the claim!
Family Practitioner with Short-Term Memory Impairment Approved for Long-Term Disability Benefits
MetLife terminated this claim based on information in the claimant’s file, which indicated that he could perform the duties of his own occupation, including an independent medical evaluation (IME) and the opinion of MetLife’s in-house psychologist.
We provided a copy of the IME report to the claimant’s treating provider and asked that he issue a statement regarding the claimant’s inability to work. We also obtained updated medical records and prepared a detailed appeal letter. MetLife completed its appeal review and determined that the claim should be reinstated.
Long-Term Disability Claim Approved for Project Director Suffering from Chronic Pain, Hyperuricemia, and Nephrolithiasis
The claimant had been receiving long-term disability benefits from MetLife for two years when the policy’s definition of disabled changed from an inability to perform his own occupation to an inability to perform any occupation. MetLife’s medical director reviewed the claim and determined that the claimant could perform several different occupations, and as such, his claim was terminated.
We obtained additional medical evidence and filed an appeal on behalf of the claimant. MetLife began its appeal review by ordering an independent physician consultant review and invoked its right to an extension. MetLife eventually provided us with a copy of the review, we responded, and we later received notification that the claim had been reinstated.
Principal
Long-Term Disability Benefits Reinstated for Electronic Technician Suffering from Cervical Radiculopathy
Principal Life Insurance terminated our client’s claim for long-term disability benefits after the definition of disability changed from “own occupation” to “any occupation.” We to prove that our client could not perform “any occupation.”
Although the claimant had already filed an appeal when he contacted our office, we secured a 30-day extension to obtain and submit additional evidence supporting the appeal. After the appeal was finalized, Principal ordered a physician file review. Based on the results of this review, Principal determined that they would pay monthly benefits while waiting for an independent medical examination (IME).
Following the IME, we received notification from Principal that the claim would be reinstated.
Sedgwick
Mobile Mechanic Approved for Long-Term Disability Due to Degenerative Arthritis and Neck and Back Pain
Our client filed a claim for long-term disability benefits due to degenerative arthritis in his bilateral knees and shoulders and neck and back pain. Sedgwick reviewed medical documentation from the claimant’s treating providers and ordered a peer review conducted by an orthopedic surgeon; however, Sedgwick denied the claim due to a lack of “objective medical evidence” to support it.
We appealed the denial and provided Sedgwick with additional medical records and a physical capacities evaluation form, which detailed the claimant’s inability to stand or walk for an extended period or lift over 25 pounds. After a review of the records that we submitted, Sedgwick approved the claim.
State Farm
Successful Long-Term Disability Appeal for Property Manager with Congestive Heart Failure
This claimant filed a claim for disability benefits with State Farm and indicated that he could not work beginning in September 2014; however, the attending physician’s statement indicated that he was first treated in January 2017. As such, State Farm updated his date of disability to January 2017. State Farm also asserted that he was not working in January 2017, so his benefits would depend on his ability to perform any occupation for which he is reasonably qualified by education, training, or experience.
We provided an occupational capacity evaluation with details regarding the claimant’s self-employment along with two attending physicians’ statements and a cardiac medical source statement to support his claim, and less than one month later, the claim was approved.
AT&T
Professional Systems Administrator with Lupus, Rheumatoid Arthritis, and Hashimoto’s Thyroiditis Approved for Long-Term Disability Benefits
AT&T Integrated Disability Service Center terminated our client’s claim for long-term disability based on the opinions of a physician advisor who never met or treated our client. The advisor claimed that the claimant’s doctor contacted him and indicated that the claimant’s conditions would not preclude her ability to return to work. AT&T also ordered a transferable skills analysis, determining that alternative occupations are available.
We filed an appeal and submitted additional medical evidence to the quality review unit, and the unit determined that the previous denial should be reversed.
[Note: Due to AT&T’s claims handling methods, we no longer handle claims with AT&T.]