A recent court decision from another state makes a few important points that Wisconsin workers can benefit from. The plaintiff in the case suffered from chronic fatigue syndrome, a medical condition we discussed in our June 2 post. Unable to work, the plaintiff filed for and received long-term disability insurance benefits.
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.
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.)
A couple of weeks ago we overheard someone at lunch talking about his disability claim. He was talking about a ski trip he'd taken a few years back that ended abruptly when he broke his left leg and right wrist in a nasty fall. He was laid up for weeks, and he had applied for long-term disability benefits through his job.
The Ninth Circuit appeals court ruled that a 47-year-old California man should be awarded long-term disability payments for his extreme case of Chronic Fatigue Syndrome. The federal appeals court found the insurance company's denial of long-term benefits was "illogical" and "implausible." A federal district court in California ruled in favor of the insurance company, but the Ninth Circuit appeals court reversed the decision.