We are continuing the discussion from our last post about how insurance companies determine eligibility for benefits. A recent case out of the 8th U.S. Court of Appeals shows how heavily one insurance company relied on physician reports in a long-term disability benefit claim. The case itself did not originate in Wisconsin, but we chose it because, under some circumstances, Wisconsin courts must follow decisions from the 8th Circuit. (The 8th Circuit decides long-term disability claims brought by people in Minnesota, Iowa, Missouri, Arkansas, Nebraska, South Dakota and North Dakota.)
The case involved a company's full-time employee who developed hip problems in early 2005, about five years after he started his job. He applied for and received short-term disability benefits that several months later converted to a claim under the employer's group long-term disability insurance policy.
His physician, Dr. B, cleared him to return to work in February 2006. The doctor's report noted that the claimant had other problems with his knees and his other hip.
A few months after the claimant returned to work, he told his employer that he was in so much pain he could not work. His primary doctor, Dr. A, assessed the claimant's condition and indicated on an insurance form that he did not believe the claimant could ever return to work.
Once again, the claimant received disability benefits. A nurse/vocational consultant with the insurance company reviewed his medical records and agreed that benefits were due. The claimant spent the next six months receiving disability benefits and being treated for the pain and a newly diagnosed carpal tunnel condition.
In January 2007, two things happened. First, the claimant received a clean bill of health for the carpal tunnel. Second, he was approved for Social Security Disability benefits.
This is where an understanding of the long-term disability plan is critical. We'll get into it in our next post.
Alan Olson writes this web-log to provide helpful information regarding long-term disability cases. He practices long-term disability law throughout the United States from his offices in New Berlin, Wisconsin. Attorney Olson may be contacted at [email protected] with questions about the information posted here or for advice on specific disability benefit claims
Source: Leagle.com, Carrow v. Standard Insurance Co., --- F.3d ----, C.A.8 (Mo.)