• Menu
  • Skip to right header navigation
  • Skip to main content
  • Skip to primary sidebar
  • Skip to footer

Before Header

Has your disability claim been wrongfully denied or terminated? Call us today for help!  (888) 321-8131

  • Facebook
  • LinkedIn
  • YouTube

OLF Ortiz Law Firm National Disability Attorneys

Ortiz Law Firm is dedicated to helping people recover the disability benefits they deserve. We handle group Long Term Disability (LTD) claims, individual disability insurance policy claims, ERISA disability claims, and Social Security Disability claims.

  • ABOUT US
    • Nick Ortiz
    • Our Team
    • Case Results
    • Testimonials
  • PRACTICE AREAS
    • Long Term Disability
      • Long Term Disability Appeals
      • Long Term Disability Lawsuits
      • Lump Sum Buyouts/Settlements
    • ERISA Disability Claims
    • Individual Disability Insurance
    • Social Security Disability Claims
      • Initial Applications for Social Security Disability
      • Request for Reconsideration
      • Hearing Before an Administrative Law Judge
    • Long Term Care Insurance Claims
    • Personal Injury Claims
  • DISABLING CONDITIONS
    • Long Term Disability
    • Social Security Disability
  • INSURANCE CARRIERS
    • View All
    • Insurance Company Tricks And Tactics
  • RESOURCES
    • Blog
    • eBooks, Guides, and More
    • Lump Sum Disability Buyout Calculator
    • Long Term Disability FAQs
    • Social Security Disability FAQs
    • Long Term Disability Glossary
    • Individual Disability Insurance Policy Analysis
    • Long Term Disability Federal Court Case Summaries
    • Abbreviations in Social Security Disability Claims
  • Search
  • CONTACT

Mobile Menu

Call us today for help!

(888) 321-8131
  • ABOUT US
    • Nick Ortiz
    • Our Team
    • Case Results
    • Testimonials
  • PRACTICE AREAS
    • Long Term Disability
      • Long Term Disability Appeals
      • Long Term Disability Lawsuits
      • Lump Sum Buyouts/Settlements
    • ERISA Disability Claims
    • Individual Disability Insurance
    • Social Security Disability Claims
      • Initial Applications for Social Security Disability
      • Request for Reconsideration
      • Hearing Before an Administrative Law Judge
    • Long Term Care Insurance Claims
    • Personal Injury Claims
  • DISABLING CONDITIONS
    • Long Term Disability
    • Social Security Disability
  • INSURANCE CARRIERS
    • View All
    • Insurance Company Tricks And Tactics
  • RESOURCES
    • Blog
    • eBooks, Guides, and More
    • Lump Sum Disability Buyout Calculator
    • Long Term Disability FAQs
    • Social Security Disability FAQs
    • Long Term Disability Glossary
    • Individual Disability Insurance Policy Analysis
    • Long Term Disability Federal Court Case Summaries
    • Abbreviations in Social Security Disability Claims
  • Search
  • CONTACT
You are here: Home / Case Summaries / Court Finds Reasonable Basis for USLIC Denial

Court Finds Reasonable Basis for USLIC Denial

May 14, 2021 //  by Ortiz Law Firm

Mr. Calkin was a 65-year-old manager of architectural design for AIG from June 10, 2013, through June 24, 2014. Mr. Calkin suffered from impingement syndrome in his left shoulder, brachial plexopathy (a form of neuropathy), bilateral shoulder pain, lower back pain due to degenerative disc disease and stenosis in his lumbar spine, degenerative joint disease in his left knee, as well as pain in his right elbow. His conditions further required the use of opioids which carried a variety of side effects including fatigue, irregular sleep patterns, and difficulty focusing or staying on task. Mr. Calkin sued United States Life Insurance Company in the City of New York (USLIC) pursuant to the ERISA act of 1974.

For Mr. Calkin to win his ERISA claim against USLIC he must have been disabled during his elimination period under the given insurance policy. Disabled means “the company has determined that there has been a change in your functional capacity to work as a result of your sickness or injury began while you are covered under the group policy and that:

  • you are unable to perform all the material and substantial duties of your regular occupation due to your sickness or injury; and
  • you have a 20% or more loss in indexed monthly earnings due to the same sickness or injury.”

Further, “If you are disabled during the elimination period and the next 24 months, you will continue to receive payments beyond 24 months of disability, if you are also: working in any occupation and continue to have a 40% or more loss in your indexed monthly earnings due to your sickness or injury; or not working, and due to the same sickness or injury, are unable to perform the duties of any gainful occupation for which you are reasonably fitted by education, training, or experience.” Each elimination period is different, and Mr. Calkins was 182 days. In order to be eligible for benefits, the claimant must have a continuous disability during this elimination period.

Mr. Calkin’s own treating physicians wrote Attending Physician Statements (APS) stating that he was severely disabled and found that Mr. Calkin had severe limitations putting him at below even sedentary exertional levels. Specifically, the second APS written by Mr. Calkin’s treating physician stated that he could only stand two hours at a time, could not stand or walk continuously even with standard employer breaks, and could only lift up to 5lbs. However, USLIC contracted a physician who reviewed Mr. Calkin’s medical records and made a determination without even seeing him in person. Based on just a review of the record, this contracted physician concluded that Mr. Calkin could still perform all the material and substantial duties of his regular occupation, even with some restrictions.

ERISA claims carry an “arbitrary and capricious” standard of review. This means that in order for a claimant to be successful there must be no “reasonable basis” for the insurance company to deny the claim. For Mr. Calkin, the report conducted by the physician hired by UNLIC satisfied a reasonable basis to deny coverage.

The court ultimately found that Calkin’s medical records during the elimination period did not show that he was incapable of mere sedentary work. The court rejected all of Mr. Calkins treating physician opinions and Attending Physician Statements. While Calkin had many physical conditions that were ailing him, the medical records during the elimination time period found that he had good ROM (range of motion) in his bilateral shoulders and that both his knee as well as his elbow were not problematic during the elimination period. The court also found that there was no change in Calkins functional capacity even though he did have physical ailments. The court then denied Calkin’s request for summary judgment and found that he was not disabled during the elimination period because he was not unable to perform all the material and substantial duties of his occupation due to his sickness or injury.

If UNLIC or any other insurer has denied your claim for long-term disability benefits, it is imperative to consult with our law firm prior to handling any appeal on your own. Our law firm has the requisite knowledge and experience to help you perfect your appeal and obtain benefits. If UNLIC or any other insurer has denied your claim, please call us at (888) 321-8131 to evaluate your claim.

[Note: this claim was not handled by the Ortiz Law Firm. It is merely summarized here for a better understanding of how Federal Courts are handling long-term disability insurance claims.]

Here is a copy of the decision in PDF: Calkins_v_USLIC

FacebookTweetPinLinkedInPrintEmail

Insurance Company: AIG Benefit Solutions, United States Life Insurance Company of New YorkOccupation: Manager

Primary Sidebar

Top Ten Mistakes That Will Destroy Your Long Term Disability Claim

View All Resources

"I highly recommend Ortiz Law Firm. Very friendly staff. They helped me win my appeal against Liberty Mutual. Thank you all for being the best!!"

Lavanda T.

View All Testimonials

Learn More About Long Term Disability

  • Areas We Serve
  • Frequently Asked Questions
  • Denials and Appeals
  • Your Chances of Getting Approved
  • Medical Eligibility
  • Additional Parts That Do Not Happen in Every Case
  • Medical Conditions That May Qualify
  • Long Term Disability Insurance Carriers
  • Occupations That May Qualify
  • LTD Federal Court Case Summaries

Footer

Contact Us

Our experienced disability law firm is ready to fight for you. Contact us today for a free case evaluation.

(888) 321-8131
316 S Baylen St., Ste 590
Pensacola, FL 32502

  • Email
  • Facebook
  • LinkedIn
  • YouTube

Claims We Handle

  • Group Long Term Disability
  • ERISA Disability Claims
  • Individual Disability Insurance
  • Social Security Disability Claims
  • Long Term Care Insurance
  • Florida Personal Injury

Quick Links

  • About Us
  • Free Resources
  • Client Testimonials
  • Case Results
  • Nationwide Representation
  • Refer a Case

Site Footer

© 2023 Ortiz Law Firm

Sitemap | Disclaimer | Privacy Policy

Share this ArticleLike this article? Email it to a friend!

Email sent!