We are finishing up our discussion of an 8th Circuit case that highlights the complexities of insurance companies’ benefits decisions. Each decision is based on the opinions of a number of professionals, including the treating physician(s). The plan in this case defined two long-term disability benefit periods: In the first 24 months, the claimant cannot perform his own job; after that, he cannot perform any job.
The insurance company denied benefits after the first 24 months. The claimant’s treating physician had said he was unable to work at any job, but the insurance company’s reviewing physician thought otherwise. The reviewing doctor’s opinion, however, was based in part on a misreading of the record. The claimant appealed.
The appellate court found that the insurance company’s process was thorough, regardless of the differences of opinion of the doctors. When the claimant’s physician sent letters attempting to correct the insurance company’s reading of something, the insurer reviewed the information. It seems that, as long as the company was fair, it didn’t have to be right.
Finally, the claimant argued that the same medical information qualified him for Social Security disability benefits, so he should likewise qualify for LTD benefits. The court disagreed. The employee plan and the government plan were not related to one another, and the SSD decision held no sway over the plan.
We understand that this has been a long explanation, but we wanted to use a real-life case to illustrate a few points. First, in an LTD claim, the insurance company generally controls the purse strings. Second, the process is complicated. Third, courts allow insurance companies “considerable discretion” (the court’s words) in benefit decisions, and that can end up costing the claimant his benefits.
When you’re busy coping with a health crisis, you want help navigating the LTD and SSD systems. As this case shows, not crossing a “t” or missing the dot on an “I” can justify an insurer’s rejection of the claim.
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.)