“Bill” approached our firm after his long-term disability claim against The Hartford was improperly denied. His occupation as a Global HR Business Partner at AstraZenica required a blend of strategic insight, interpersonal skills, and the ability to handle various responsibilities ranging from workforce planning to addressing employee relations issues.
The Effects of Rheumatoid Arthritis and a Neuropathy
Unfortunately, “Bill’s” ability to perform these duties was severely compromised due to a debilitating combination of Rheumatoid Arthritis (a chronic inflammatory disorder affecting joints, including those in the hands and feet), significant Neuropathy (damage or dysfunction of one or more nerves, resulting in numbness, tingling, muscle weakness, and pain), and a subsequent seizure indicating a possible underlying dysautonomia (a disorder of the autonomic nervous system, which controls involuntary bodily functions such as heartbeat, blood flow, and digestion) or central nervous system disorder.
These medical conditions not only impaired his physical capabilities but also his mental resilience, making it impossible for him to continue in his professional role.
The Hartford Initially Denies the Claim
Bill’s initial claim for benefits was denied by The Hartford, one of the major insurance companies writing group long term disability policies in the United States.
The initial application for benefits submitted to Hartford was denied based on it’s assessment that “Bill” did not meet the policy’s definition of disability under the “own occupation” standard. Generally, long-term disability policies will pay a benefit if the claimant cannot perform his or her “own occupation” during the first two years of a claim. The analysis of a claim under the “own occupation” standard requires a close look at the material duties of the occupation as it is performed in the national economy.
Hartford Used a Retired, Non-Practicing Doctor to Deny the Claim
In this case, Hartford relied on the evaluations conducted by two of their hired specialists, who concluded that there were no supported physical restrictions and limitations preventing “Bill” from performing the duties of his occupation as a Global HR Business Partner. Despite “Bill’s” complex medical conditions, including Rheumatoid Arthritis, significant Neuropathy, and the aftermath of a seizure possibly linked to dysautonomia, Hartford’s reviewers determined there was an absence of impairing diagnoses from both an occupational and psychiatric standpoint. This assessment directly led to the cessation of “Bill’s” long-term disability benefits, as it was argued that the available medical information did not substantiate an inability to fulfill his job responsibilities.
Hartford’s file was reviewed by Dr. Steven Barnett, PhD, and Dr. Byron A. Niebruegge, who is Board Certified in Preventative Medicine and Occupational Medicine but who no longer is in practice. Dr. Niebruegge opined that there were no supported restrictions and limitations due to a physical condition and that there was no impairing diagnosis from an occupational medicine standpoint. Dr. Barnett reviewed the medical information provided and concluded that there were no psychological conditions that were functionally impairing from a psychiatric perspective.
Evidence Submitted During the Appeal
The BenGlassLaw long-term disability team provided a comprehensive set of new evidence in support of the appeal for “Bill’s” long-term disability benefits, and included the following:
Personal Statement from “Bill”: A detailed narrative from “Bill” himself, describing how his disability has drastically affected his daily life and hindered him from returning to work. This statement offers insight into the severe impact of his conditions on his quality of life, his physical abilities, and his profound loss of enjoyment in previously valued activities.
A personal statement is an essential element of a long term disability appeal.
PainScale Report: This report provides documented evidence of “Bill’s” pain levels, offering a detailed account of the chronic and severe pain he experiences.
A pain scale report is a tool commonly used in medical settings to assess and document a patient’s pain levels. The report typically involves a scale that helps quantify pain intensity, ranging from no pain to the most severe pain imaginable.
Here are some key characteristics of a typical pain scale report:
- Pain Scale Type: Various scales may be used, such as the Numeric Rating Scale (0-10), where 0 means “no pain” and 10 represents “the worst pain possible.” Another example is the Visual Analog Scale (VAS), which uses a horizontal or vertical line marked from “no pain” to “worst pain.”
- Patient’s Input: The patient is asked to rate their pain by choosing a number or marking a point on the line that corresponds to their pain level. This helps ensure the assessment is subjective and based on the patient’s personal experience of pain.
- Qualitative Descriptors: Often, qualitative descriptions accompany the numeric ratings, like mild, moderate, severe, or descriptions of the pain type (e.g., sharp, dull, throbbing).
- Contextual Information: The report might also include information about the duration of the pain, activities that exacerbate or alleviate the pain, and its impact on daily functions.
Letters from a number of treating physicians who fully supported the claim: These reports and letters providing expert insight into his medical status and the implications for his functional capacity.
Functional Capacity Evaluation Report: An objective assessment of “Bill’s” physical abilities and limitations, demonstrating the significant restrictions he faces.
A Functional Capacity Exam (FCE) is an evaluation used to assess an individual’s ability to perform work-related tasks and to determine the level of physical activity they can safely handle. This exam is typically conducted by physical therapists or other healthcare professionals and is used for various purposes, including determining fitness to return to work after an injury, assessing disability claims, or formulating rehabilitation programs. The FCE involves a series of standardized physical tests that measure strength, endurance, flexibility, and range of motion, as well as other physical and sometimes cognitive capabilities, relevant to the job tasks. The results help define the physical limitations of a patient and can guide recommendations for work accommodations or restrictions.
Letter from Unum Insurance Company approving “Bill’s” claim for Any Occupation under a separate insurance policy: This letter indicates recognition from another insurance company of “Bill’s” inability to work in any occupation, providing a supportive third-party perspective on his disability.
The Legal Arguments in the Appeal
Here is an article about what you should do to appeal your long-term disability denial.
In this case, BenGlassLaw made several legal arguments in its appeal to contest the denial of long-term disability benefits for “Bill.” These arguments focused on demonstrating that the denial violated the requirements and protections afforded by the Employee Retirement Income Security Act of 1974 (ERISA). The appeal highlighted that ERISA was enacted to protect the interests of employees and their beneficiaries in employee benefit plans. It emphasized that ERISA imposes a higher-than-marketplace quality standard on insurers, requiring plan administrators to act solely in the interests of participants and beneficiaries, ensuring a “full and fair review” of claims.
The appeal argued that Hartford’s denial was arbitrary and capricious because it failed to follow ERISA’s procedural requirements. These requirements include making decisions based on the plan language, providing a deliberate, principled reasoning process supported by substantial evidence, and stating all reasons for denial upfront without introducing new reasons post-appeal or during litigation.
BenGlassLaw contested Hartford’s interpretation and application of the medical evidence, asserting that the insurer disregarded or improperly dismissed the opinions of “Bill’s” treating physicians. It argued that under ERISA, a plan administrator cannot arbitrarily ignore or discount the treating doctors’ opinions without a sound, evidence-based reason.
The firm argued that Hartford failed to properly consider the combined effect of “Bill’s” medical conditions on his ability to work, focusing instead on isolated aspects of his health. The appeal stressed that ERISA requires a comprehensive assessment of a claimant’s overall medical situation, including how the interplay of multiple conditions affects their capacity for employment.
BenGlassLaw contended that Hartford improperly disregarded “Bill’s” subjective complaints of pain and other symptoms. It highlighted that ERISA mandates insurers to meaningfully address and not dismiss self-reported symptoms, especially when such symptoms are supported by medical evidence and professional opinions.
By focusing on these legal arguments, BenGlassLaw aimed to demonstrate that Hartford’s decision to deny “Bill’s” long-term disability benefits was not supported by the evidence, nor was it in accordance with ERISA standards and procedural requirements. The appeal sought to rectify what was presented as an unjust denial, advocating for the rightful approval of “Bill’s” claim based on the legal protections meant to ensure fair and equitable treatment of plan participants.
Additional Resources:
BenGlassLaw’s Ultimate Guide to Mastering Long-Term Disability Claims
What High Wage Earners Need to Know About Long-Term Disability Claims
How Much Should You Pay a Good Long Term Disability Attorney
The BenGlassLaw Long-Term Disability YouTube Channel
BenGlassLaw feature article at Premier Financial Website
Listen to Ben Glass Argue Long-Term Disability Cases in Court. Want to hear Ben work before you hire the BenGlassLaw Disability Team? You can listen to Ben Glass at work in long-term disability cases here.
Future Benefits Will Exceed $1.8 Million
Back benefits were restored and ongoing benefits are about $10,000 per month. If the claimant remains disabled through age 67, his total benefit recovery will be $1,825,333.33.