Disability benefits appeal denied despite primary MD’s report p3

Starting a new job usually includes a review of the benefits plan with a human resources representative. The summary sheets give a broad overview of health and dental plans, life insurance and short- and long-term disability insurance. Most of the time, that’s the last time the employee thinks about those benefits — until he needs them.

We’ve been talking about a case out of the 8th U.S. Court of Appeals that involved an employee whose long-term disability benefits claim turned on the insurer’s interpretation of doctors’ reports. It isn’t our job here to question the court’s decision. We just want to show how disability plans work.

Generally, insurance companies make coverage decisions. A homeowner’s policy describes what’s covered, but the insurance company decides if what happened really counts as what’s covered.

A disability plan necessarily includes a definition of the term “disability.” In this case, the definition had two parts. For the first twenty-four months, the employee had to be disabled from his “own occupation” in order to qualify for benefits. After that, he had to be disabled from “any occupation” that “reasonably” fits the claimant’s “education, training and experience.”

Short-term benefits only last so long. If a claimant’s condition keeps him away from work longer than that period, the benefits convert to long-term disability benefits. In some plans, after a certain number of months on LTD, the claimant must apply for Social Security Disability benefits. This happened to our claimant — he began receiving SSD benefits in January 2007.

In this plan, the “own occupation” to “any occupation” conversion happened at about the same time the SSD benefits kicked in. That conversion required a review by the insurance company based on a questionnaire completed by the treating physician.

That’s where the confusion started.

We will finish this up next week.

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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.)

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