Just How Disabled Does a Long-Term Disability Claimant Need to Be to Receive Benefits

J.P. Gonzalez-Sirgo
Founder of J.P. Gonzalez-Sirgo, P.A.

Whether you are a nurse in a hospital, nursing home, or outpatient facility, the physical demands of your job can lead to long-term disability.  These disabilities can be the result of a back injury while assisting a patient who slips while walking or a severe knee injury incurred in a fall on a wet floor.  If you are responsible for a significant amount of your household income, you might well count on long-term disability insurance to replace your lost income.  Most people know that long-term disability insurance provides income replacement when a person suffers a debilitating injury or illness, so he or she cannot work.  Many policyholders have no idea how creative insurance companies and their well-compensated experts are prepared to justify denying a claim.  Although the appellate court case discussed below is from another jurisdiction, the ridiculous contentions by the insurance company and its experts contending that the insured was not disabled provides a valuable lesson for long-term disability claimants in any state.

A federal district court in California in LaVertu v. Unum Life Ins. Co. evaluated the appropriateness of an insurer’s decision to discontinue long-term disability benefits to its insured.  Lavertu had worked as an administrative assistant at an insurance company.  She filed for disability after suffering chronic back pain.  The insurance company commenced paying benefits, which were paid for a two year period.    However, the insurer eventually terminated benefits based on the contention that Lavertu was no longer disabled under the definition provided in the insurance policy.  When the insured’s appeal to the insurer was denied, she filed a lawsuit.

During the lawsuit, LaVertu introduced evidence that she had endured three distinct spinal surgeries in an attempt to repair the damage to her spine.  The procedures provided no relief, and the policyholder eventually was awarded disability benefits under the Social Security Act.   The insurance carrier sought discovery of the entire Social Security disability claims file.  Based on the file, the insurer’s own in-house vocational consultant conceded that the file supported a conclusion the insured could only sit for a period of four hours per day.  Thus, the vocational consultant reasoned that the insured was unable to meet the exertional demands of a sedentary occupation.  Other evidence introduced in the lawsuit included an internal note that indicated, “Clmt is [totally disabled] any occ and R&Ls are permanent.”  The insurer contacted the policyholder and represented that no improvement in the insured’s medical condition was anticipated, so benefits were being extended.

After two years, a physician conducted a paper review of the claims file and issued an opinion that LaVertu was able to perform full-time sedentary work.  The doctor recommended that this conclusion be verified through an independent medical examination.  The report from the examination advised that the insured could perform part-time sedentary work with hourly 10 minute rest breaks.  The insurance company sought legal guidance on whether it could terminate benefits based on the insured’s ability to perform part-time work with these limitations.  While the legal department indicated this was not a legal basis to terminate benefits, the insurer did so anyway.

The court evaluating the evidence determined that the insured was disabled because there was no evidence her condition was improving.  The court also observed that limited walk, stand and sit capabilities preclude sedentary work.  The judge citing Gordon v. Northwest Airlines, Inc. Long term Disability Income Plan observed, “Common sense dictates that someone who cannot walk, sit or stand more than 2.5 hours per day cannot do sedentary work.”

Despite substantial evidence from vocational experts and physicians, the insurer in this case continued to advance the specious argument that the ability to engage in extremely limited part-time sedentary work means an individual is not disabled.  The notion that a person is able to engage in a sedentary job but only with ten minute breaks on an hourly basis might seem ludicrous, but the position taken by the insurance company demonstrates how far a carrier will go to avoid paying a long-term disability claim.

Our Miami long-term disability insurance claims law firm invites you to contact us if your insurance carrier refusing to comply with its contractual obligation.  If you are a beneficiary with questions about disability insurance claims, you are invited to contact our law firm to speak to an experienced Miami insurance claims attorney.  My law firm specializes in representing policyholders in claims disputes in Miami and throughout Florida. Click here to read about some of our case results.  The Law Firm of J.P. Gonzalez-Sirgo, P.A. offers free consultations and case evaluations. No Recovery, No Lawyer Fees. Call 305-461-1095 or Toll Free 1-866-71-CLAIM. 

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