The conduct of insurers in the long-term disability world can sometimes be incredible. Today's client story is an example of an insurer's frustratingly unbelievable conduct.
Mr. Mitchell was a hard worker. He went to work right out of high school in a grocery store. He worked his way up to be a butcher. Then, he got on with a utility company. His job was installing poles. It was a physical job, but he didn't mind the hard work. There, he worked his way up to team leader. One day at work, he stepped in a hole and hurt his back. That was the beginning of the end of his career, and he was only in his fifties.
His employer required him go to their worker's compensation doctor about his injury. Surgery was required. He grudgingly had the surgery which was followed by physical therapy.
After being out of work six months, Mitchell pressed the doctor to release him so that he could return to work. The doctor finally relented and allowed him to return to work with modified duties. But, Mitchell's restrictions were so severe that his employer said he was a liability simply being on their grounds. He was crushed when they said “we can no longer use your services.”
He had a long-term disability benefit which would pay 70% of his monthly salary. He was getting a modest worker's compensation benefit, so he did not know if he also qualified for a long-term disability benefit. But, his plan allowed both, so he filed a claim. His claim was allowed but the long-term disability benefit was offset by his worker's compensation as provided by the policy.
The long-term disability insurer required him to file for Social Security disability. It threatened to reduce his benefit if he did not. He filed for Social Security disability. The Social Security Administration ruled in his favor and found him to be disabled from any occupation. Despite the Social Security finding and having agreed to pay his claim, the insurance company reversed its position and said that he was not disabled. It denied his claim.
Mitchell contacted us for help. He had already appealed the denial of his claim. We asked him to withdraw the appeal so that we could work up the case and strengthen his claim record. Despite his beefed-up claim record and their inexplicable about-face, the insurance company maintained its refusal to pay his claim. We filed suit. The evidence (claim record) was so convincing, someone reasonable at the insurance company finally took notice. We were able to settle the case.
ERISA cases can be frustrating. Not only is the law unfamiliar, but the conduct of insurers can be unbelievable. Because there are no punitive damages or mental anguish allowed, there is often little incentive for insurance companies to act reasonably. We're used to it. We know how to build the case so that the best results can be obtained as efficiently as possible. If you find yourself with a frustrating ERISA situation, give us a call.