Northern Virginia Personal Injury Lawyer - Disability insurance

Beware of any Group Disability Policy

Ben Glass — Mon, 15 Jun 2009 13:57:00 GMT

Many professional athletes find themselves doing battle with their sports group disability plan insurance carrier.

In 2006, an appeals court awarded the estate of former Pittsburgh Steelers center Mike Webster more than $1.5 million in disability pay from the plan. It was the first successful challenge of the plan's rules and it has given hope to many of the players who feel left out.

While this is a victory for the players, I can tell you that any athlete seeking disability pay from these plans faces an uphill battle.

Most group long term disability polices (those offered by employers) stink. If you can afford to, and you want real disability insurance, you should be talking to a broker about a private/individual policy.

Most group policies aren't worth the paper they are written on because:

1. The protect you if you can't work in your own occupation for only 2 years.

2. If any part of your disability is caused by a mental or nervous disorder, the limit is generally 2 years. (And the disability insurance companies will do their best to lump your disability into the mental and nervous box.

3. Group policies are governed by ERISA. This means, generally, that the insurance company's decision on your claim is entitled to the benefit of the doubt and can only be reversed by a court for an abuse of discretion. This means you have to show that they are really, really wrong.

Originally posted at InjuryBoard by Ben Glass

Praise for Robbery Without a Gun-Why Your Employer's Long-Term Disability Policy May be a Sham

Ben Glass — Thu, 18 Dec 2008 20:55:51 GMT

North Carolina social security disability attorney Brent Adams recently said this about Robbery Without a Gun, the book which exposes the games of the long-term disability insurance companies.

Glass discusses how a law which was intended to protect workers has been perverted by Federal Judges into a tool with which to line the pockets of the “fat cat” corporate bosses at the expense of disabled workers and their families.

Although the book deals with complex legal issues, Glass distills the essence of the issues into an easy to understand explanation.

You can read what else Brent Adams said this disability insurance book here.

Originally posted at InjuryBoard by Ben Glass

Senate Finally Questioning Dubious Disability Insurance Practice

Ben Glass — Fri, 25 Jul 2008 06:24:49 GMT

Its about time that someone investigated this practice of the major disability insurance companies:

Because their group policies allow them to reduce their payments to claimants if the claimant gets social security disability payments they often require claimants to apply for social security disability even though they know darn well that they won't qualify.

Most long-term disability policies protect you and provide payments if you can't work at your occupation...but you don't need to be so disabled that you would qualify for benefits, yet UNUM and the other "majors" often require claimants to go through the process, even to the point of forcing claimants to appeal initial SSDI denials.

This is extremely wasteful of government resources and is probably part of the reason why there is a huge back up of claims-processing for social security claims

The New York Times has this story this morning.

My book, Robbery Without a Gun, exposes other deceptive practices of the disability insurance companies.

Originally posted at InjuryBoard by Ben Glass

Huge Victory in Virginia for Long-Term Disability Claimants

Ben Glass — Thu, 12 Jun 2008 17:33:41 GMT

Yesterday, the Fourth Circuit Court of Appeals dealt a major blow to Prudential Insurance Company of America in an ERISA group long-term disability case involving a claim for benefits.

The case is Patricia Woods v. Prudential Insurance Company of America.

The big issue in these all of these ERISA disability cases is whether a federal judge can look at a claim denial "all over again" or whether he has to grant deference to the insurance company administrator denying the claim.

In order to grant deference, the disability plan must have certain magic language in it "granting discretion" and the language must be stated in a very specif way.

The Court of Appeals ruled that standard language that Prudential uses in its plans does not grant discretion and that claims must be reviewed de novo.

This could effect thousands of Prudential group long term disability insurance policies and is a major victory for claimants.

Originally posted at InjuryBoard by Ben Glass

Prudential Didn't Use Qualified Doctors to Deny Disability Claim

Ben Glass — Mon, 24 Mar 2008 14:11:52 GMT

Graham Harrison, filed for disability benefits under his group long term insurance policy provided by Prudential Insurance Company.

He suffered from Tourette Syndrome which prevented him from working on a full time basis. His doctor, a neurologist and specialist in his disease (Tourette Syndrome) had recommended that he consider reducing his work schedule to less than full time to accommodate his condition which have led to chronic anxiety, a disrupted sleep pattern and agitation. His physician felt that a four day work week with a mid week break would benefit him immensely.

Prudential first paid, then denied the request for benefits. Prudential's position was that since he had suffered Tourette's Syndrome for many years his records did not document a significant recent change that would warrant a change in his work patterns. Prudential also felt that if he could work four days there was no reason that he could not work five days in a week.

At first Prudential relied on the opinion of its "medical director", Jill C. Fallon, M.D., a doctor who was Board Certified in occupational medicine but had absolutely no expertise in neurology or Tourette's Syndrome. This doctor did not even examine the claimant.

Prudential also looked at the wrong definition of disability in denying the claim.

Mr. Harrison appealed the denial of benefits and included additional reports from his well qualified physicians. On appeal, Prudential showed the file this time to Albert Kowalski, M.D. another one of its employed physicians. Not only did Dr. Kowalski not have Board Certifications in neurology or psychiatry, he had absolutely no experience in the treatment of Tourette Syndrome and indeed had not had any clinical practice since 1987. Dr. Kowalski did not examine the claimant. Despite the lack of qualifications and any current experience in actually seeing patients, Dr. Kowalski was of the opinion that the claimant's condition should have improved over time.

On the basis of Dr. Kowalski's opinion, Prudential denied the claim. In denying the appeal Prudential once again quoted the wrong definition of disability. The plaintiff again appealed and this time consulted with yet another expert in Tourette Syndrome. He was evaluated by Oliver Sacks, M.D. a clinical professor of neurology at Albert Einstein College of Medicine and an adjunct professor of neurology at the New York University School of Medicine. Dr. Sacks had authored numerous books and articles on Tourette Syndrome. It was Dr. Sacks' opinion that Mr. Harrison could maintain his effort and function very effectively for only two days at a time and then must take a break of a day to recover. He cannot function on a "standard" five day week. On the basis of this letter Prudential reversed its original decision and awarded benefits to the plaintiff. Prudential however continued to misstate policy provisions and indeed quoted language that appeared nowhere in the plan.

Two months after approving the claim Prudential began re evaluating the claim. This time Prudential took the position that the plaintiff's disability was caused at least in part by a mental psychoneurotic or personality disorder and that benefits were limited to 24 months. Prudential advised the claimant that his claim would most likely terminate the next month.

The problem with Prudential's denial of benefits this time was that there was no 24 month limitation in this policy.

Prudential also referred the file to Stephen N. Gerson, M.D. Dr. Gerson was Board Certified in psychiatry and geriatric psychiatry but listed his major professional activity as "administration." There was no evidence in the file that Dr. Gerson had any experience in the treatment of Tourette's Syndrome. He did not examine the claimant. It was Dr. Gerson's opinion that the various treating physicians and the claimant himself were simply making a "preference" for not working a five day work week. Shortly thereafter Prudential terminated benefits yet again.

Mr. Harrison filed suit under ERISA.

The court reversed Prudential's denial. The court found that "In the worst light, such conduct [misquoting policy provisions] indicates a conscious attempt on the part of Prudential to manufacture a reason for denying plaintiff benefits."

The court also found that the decision to terminate benefits was not supported by substantial evidence. The court said that Prudential had ceased on one piece of information that one of the doctor's had relayed to it to terminate benefits. The court found that Prudential had not relied on any new information to terminate benefits after it had previously approved benefits on the same information. The court also was critical of Prudential for using doctors who had no expertise in Tourette Syndrome and who never examined the claimant.

Originally posted at InjuryBoard by Ben Glass

Another Reason for Long Social Security Claim Delays

Ben Glass — Wed, 03 Oct 2007 08:05:39 GMT

North Carolina Social Security Disability attorney Brent Adams makes and excellent point about long delays in social security disability claims. He quotes an excellent commentary from administrative law judge Ronald Bernoski, writing in the Charlotte Observer.

I've got an additional theory. Fraud by the major long-term disability insurance companies. Here's how it works:

Most long term disability policies protect you if you can't work in your "own occupation" for two years, and then if you can't work in "any occupation" after that. So, you may be entitled to benefits under that insurance policy for two years, even if you could work in some job. This is to give you time to recover from your disability and also to give you time to retrain.

However, here's what the insurance companies do. When you do qualify for benefits because you can't work at your own job they force you to apply for social security benefits. That's right, even though they KNOW you would not qualify for social security benefits (because there may be some job you can do -- you just can't do your own job).

Thus, they force the flooding of the social security administration with bogus claims. If you don't apply, they threaten to cut off your benefits.

Why do they do this?

Profit.

You see, under most group long term disability policies (the kind your employer 'gives' you) any money you do get from Social Security offsets, or reduces, what the insurance company owes you. So they force you to apply, even though in the vast majority of cases you won't qualify.

Meanwhile, as Brent Adams points out, other folks who would be qualified for benefits are waiting behind you in that long line.

Sound like a good idea?

Originally posted at InjuryBoard by Ben Glass

(More) Tricks of the Disability Insurance Companies

Ben Glass — Tue, 11 Sep 2007 15:57:15 GMT

Here's another major trick we see them use. They deny your claim and ask you to submit an appeal. When you do so they say that

"The ability to produce a detailed document such as your personal profile is indicative of an ability to produce quality work" (and thus work).

This is really a silly statement unless you know such facts as who prepared or assisted in the preparation of the document and how long it took for the document to be prepared. Courts have seen through that illogic (See Krizek v. Cigna Group Insurance, 345 F.3d 91 (2nd Cir. 2003), the Second Circuit overturned the lower Court's grant of summary judgment to the defendant in part because the District Court had no evidence to conclude that plaintiff's ability to prepare her administrative appeal discredited her complaints of pain.)

Originally posted at InjuryBoard by Ben Glass

Tricks of the Disability Insurance Companies

Ben Glass — Sat, 08 Sep 2007 15:51:06 GMT

Here's one we still see with some frequency in ERISA governed long term disability insurance claims.

The insurance company makes a decision that the claimant is not disabled, and writes (or calls) the treating docotor with this type of message:

"Dear Doctor, our review indicates your patient could work a 40 hour week, no problem. If you don't agree with our review, let us know within 10 days or we'll assume you agree."

Courts have ruled that no negative inference can be drawn from a doctor's failure to respond. (See Brenner v. Hartford, 2001 WL 224826 (D.Md. 2001) which points out: "Little significance can be attributed to Dr. Avin's unresponsiveness to Defendant's request for comments as the lack of response could as likely be a result of inadvertence or inattention due to other pressing demands in a physician's schedule." n.10)

Originally posted at InjuryBoard by Ben Glass

Long Term Disability Policies: "Robbery Without A Gun"

Ben Glass — Thu, 19 Jul 2007 07:03:31 GMT

New video and book exposes the truth about group long term disability insurance policies.
In his book, "Robbery Without a Gun", long term disability insurance attorney Ben Glass reveals the mistakes that claimants and their doctors make in a disability claim that can virtually guarantee that the claim will be denied by the insurance company.

Here's a short video where Ben explains how most group disability insurance policies aren't worth the paper they are printed on.

Originally posted at InjuryBoard by Ben Glass

Time to Sue for Disability Claims Clarified in ERISA

Ben Glass — Tue, 01 May 2007 05:53:12 GMT

The Fourth Circuit Court of Appeals has answered a very important question for long-term disability claimants: When does the statute of limitations expire when you have been denied benefits.

Sun Life Assurance Company of Canada contended that a claimant had failed to file her claim within the time limits set out in the contract. Sun Life's disability insurance policy, like most contained the following language: "No legal action may start ... more than three years after the time Proof of Claim is required."

In all cases a planned participant applies for benefits by filing a "Proof of Claim." In group disability plans covered by ERISA a claimant may not file a lawsuit until the plan has reached a final decision denying benefits. Thus the question was whether the three year time period begins to run at the time the claimant first filed her Proof of Claim or when the final decision denying benefits was made.

The Fourth Circuit of Appeals, in a case which governs ERISA claims in Virginia, ruled basically that Sun Life's claim that the three years started running at the time Proof of Claim was required was absurd because if that was the rule a claimant may have completely run out of time to file the claim before a final decision denying benefits was made.

The Fourth Court said an ERISA cause of action does not accrue until a claim of benefits has been made and formally denied. The court pointed out that other circuits have adopted this same rule for ERISA actions. This means, the court said, that the "statute of limitations begins to run at the moment when the plaintiff may seek judicial review, because ERISA plaintiffs must generally exhaust administrative remedies before seeking judicial relief. The court rejected Sun Life's request to disregard all the usual rules of accrual and to hold that ERISA plans may specify different accrual dates in their governing documents.

Originally posted at InjuryBoard by Ben Glass