Before or after her shift at the bank, Katie could be found doing what she loved best – running and spending time with her family and friends. Her job was a perfect fit. As a bank manager, she was active all day, every day. She thrived on her interactions with customers and the several full-time employees she managed. Being efficient, smart with numbers, and able to get along with a variety of people was all part of her routine.
How a crime at her workplace forever changed her life
Everything changed for Katie the day her bank was robbed. No one was physically hurt, but it was a terrifying experience. When the bank robber pointed a gun at her head, he also robbed her of her former life. Before, she couldn't be happier to be alive, but now she suffers from depression, anxiety, PTSD, and insomnia. Simply mustering up the will to leave her house triggers her symptoms. Forget about running or working a 40 hour week, especially in a public place. She struggles now just to get enough sleep and get herself to therapy.
Denial of long term disability benefits after a new case reviewer was hired
When it became clear she could no longer leave the house or run her own errands, much less return to work at the bank, Katie applied for Short Term Disability benefits. Her insurance provider, Liberty Mutual, approved her claim (of course) and paid her short-term benefits for five and a half months without issue. They had also approved long term disability benefits to start once the short term benefits finished. Two months into receiving long term disability benefits, Katie received a denial letter from Liberty Mutual. Her conditions hadn't changed. Her doctors didn’t tell her she could return to work. She still struggled to leave the house for therapy sessions and her symptoms weren't improving. Why were her benefits terminated?
Liberty Mutual simply found a new medical reviewer, Dr. David Yuppa, who would state that Katie was not disabled. Part of the records he reviewed to make this determination included 31 documents that were not even about Katie! Somehow, although they were patient records about someone else's injuries, Dr. Yuppa missed that. So how closely was he reviewing the records?
While Dr. Yuppa was looking at someone else’s records in Katie’s file, he was not looking at something very important: a job description. At least at first, a disability determination is all about whether you can do your job. To make that call, it really helps to know what your job is! Of course, Liberty Mutual’s denial letter said they had determined that Katie was able to perform the duties of her occupation. They did not explain how they could possibly know that without even knowing what her job duties were.
Nothing had changed about Katie’s condition, and Liberty Mutual didn’t even try to argue that she had improved. They denied her benefits solely because they found a new medical reviewer who didn't meet her in person, didn’t know what her job requirements were, and didn’t even realize he was reviewing the wrong records – but who would say he was sure that Katie was not disabled. That’s all Liberty Mutual needed to hear. They denied the claim.
How BenGlassLaw Was Able to Help
To prove that the denial based on Dr. Yuppa's review would never hold up in court, we highlighted a few key points in our appeal
- A disability determination must begin with a discussion of a claimant’s job duties. Liberty Mutual missed that entirely.
- A benefit denial must be supported by substantial evidence. All Liberty Mutual had was the opinion of one paid reviewer who never even met Katie and was looking at some of the wrong records. That’s not “substantial evidence.” It’s really not evidence at all!
- A mental health determination cannot be based on a paper review of the records alone. You just can make that kind of determination without actually meeting with and talking to the person whose life you are deciding.
- You can’t ignore the treating physicians. Katie’s doctors said she was not ready to go back to work. Liberty Mutual has to acknowledge that and explain (with substantial evidence again) why they disagree. They can’t just ignore the doctors.
We won the appeal. With her Long Term Disability benefits reinstated, Katie received a back benefits check of $24,000 for the months Liberty Mutual stopped paying her and now receives over $3,000 per month in ongoing benefits. She is working with her doctors and hopes that her symptoms will improve and she can start living her life again. But until that time, at least disability benefits are one less thing she has to worry about.