by Cody AllisonI’m Getting Paid Under “Reservation of Rights” — What does this mean?
When you review your policy prior to filing a claim, you are probably going to run into terms in the policy that you don’t understand. One of the terms that we get asked about most is the “reservation of rights” clause in a policy, although this is not the only “legalspeak” term you are going to run across. Below is an explanation of what this term means. This illustrates the point that it is important to get a competent professional to review your policy and give you advice about your rights under the policy, and also to explain the meanings of these terms. At Cody Allison and Associates, we stand ready to help you.
If you are receiving long-term disability benefits and have been told it’s under “Reservation of Rights”, this means that while the insurance company is still reviewing your claim to approve benefits or deny benefits, they will pay you under Reservation of Rights. After the insurance company reviews your claim and makes a decision, they will either start paying your claim normally and no longer under Reservation of Rights or they can deny your claim and you will receive no more benefits.
If you are getting paid under Reservation of Rights, please call Cody Allison & Associates at (615) 234-6000 and we will be happy to go over your claim with you free of charge. You can also e-mail our office at cody@codyallison.com. Put our experience to work for you. For more information go to www.LTDanswers.com.
by Cody AllisonWill my long-term disability claim be denied if I do not have surgery?
Occasionally, we get clients or callers who are worried because their Dr. has recommended surgery and they just don’t want to have surgery. This can be for various reasons. They are worried that if they don’t follow the course of treatment recommended by the Dr. by not having the surgery, their coverage will be denied. Below is the answer to the question of what happens if an insured chooses not to have surgery. Remember, here at Cody Allison and Associates, we are available to help you and answer any question you may have. If you have questions or concerns about your disability claim, give us a call today.
Our office gets asked this question often. My doctor has recommended surgery and indicates that other than surgery, there is nothing more he can do for me. Will my long-term disability claim be denied if I do not have surgery?
The disability carrier cannot force you to undergo surgery. For example, if you have back problems and have seen an orthopedic and a neurosurgeon, and the neurosurgeon is recommending surgery, and you do not want to undergo surgery for several reasons, the carrier cannot deny your claim for not going through with the surgery that your neurosurgeon has recommended. You can continue to treat with other conservative treatments.
If you have any other concerns or questions regarding this matter, please call Cody Allison & Associates at (615) 234-6000 and we will be happy to answer any other questions you may have. You can also e-mail our office at cody@codyallison.com. Put our experience to work for you. For more information go to www.LTDanswers.com.
by Cody AllisonIf your doctor has not released you to go back to work, your disability claim can still be denied.
There are certain rules that every claimant must know when making a disability claim under a policy. These rules are usually outlined in your policy. It is important to know them and abide by them to not give the insurer an excuse to deny the claim. However, there are some things that you may not really have any control over. In this instance, a disability claim may be denied even though your treating physician has not released you to return to work. Below is an explanation of how this can be done. If you need help with your case or feel that your claim has been wrongfully denied, please contact us to discuss the matter.
If your doctor has not released you to go back to work, your long-term disability claim may still be and can be denied. After the insurance company receives your claim, they will review your medical records and will start their own investigation of your claim. In this process, the insurance company may send your medical records to their own independent doctors to do a peer review. If any of these doctors conclude they don’t find any restrictions or limitations that prevent this individual from working, the insurance company can and most likely will deny the claim. They can deny your claim based on their independent peer review doctor’s opinion, regardless of what the treating physician or physicians who treat you regularly state.
If your treating physician states that you cannot work, or hasn’t released you to go back to work yet, and you received a denial from your long-term disability carrier, please call Cody Allison & Associates at (615) 234-6000 and we will provide you with a free case analysis.
by Cody AllisonDutkewych v. Std. Ins. Co.
In this 2015 ERISA case, there was substantial evidence that plaintiff’s mental illness, whether or not related to chronic Lyme disease, contributed to his disability as of June 2011 where reports from plaintiff’s own treating physicians established that he had ongoing mental disabilities, in addition to his physical symptoms, as of the period around June, 2011. The plan administrator’s interpretation of the Mental Disability Limitation and the Rules governing its application was by no means unreasonable and so must prevail. The plan administrator’s limitation of the plaintiff’s benefits to 24 months was not arbitrary or capricious given the substantial evidence in the record that mental disorders, regardless of their cause, contributed to his disability as of June 1, 2011.
Judgment affirmed.
If you need assistance navigating your claim for short term or long-term disability benefits under ERISA, or it is time to sue the insurance company, please do not hesitate to give Cody Allison & Associates, PLLC a call (844) LTD-CODY, (615) 234-6000. or send us an e-mail Cody@codyallison.com. We provide representation nationwide and have successfully sued all the major insurance companies in many states. Our headquarters are located in Nashville, Tennessee. We offer a free consultation and would love to speak with you.
by Cody AllisonDoe v. Std. Ins. Co.
In this 2017 ERISA case, an ERISA claims administrator acted arbitrarily and capriciously by determining an attorney’s disability onset date based on when she was disabled from performing the duties of a generic “lawyer,” rather than the specialized duties of an environmental lawyer. The administrator charged an enhanced premium for specialty coverage and unreasonably undercut that coverage by failing to consider the specific requirements of the attorney’s specialty. The appropriate remedy was an award of retroactive benefits rather than a remand to the administrator.
Judgment reversed.
If you need assistance navigating your claim for short term or long-term disability benefits under ERISA, or it is time to sue the insurance company, please do not hesitate to give Cody Allison & Associates, PLLC a call (844) LTD-CODY, (615) 234-6000. or send us an e-mail Cody@codyallison.com. We provide representation nationwide and have successfully sued all the major insurance companies in many states. Our headquarters are located in Nashville, Tennessee. We offer a free consultation and would love to speak with you.
by Cody AllisonGross v. Sun Life Assur. Co. of Can.
In this 2013 ERISA case, the longer-term disability benefits provided by an employer were subject to ERISA where the documents associated with the employee benefits program established all five constituent elements of an ERISA plan. ERISA’s safe harbor provision did not apply as the employer did not provide multiple, independent plans. The plan administrator’s rejection of the employee’s claim for benefits was subject to de novo review as the “satisfactory to us” language in the policy did not state with sufficient clarity that the administrator was to make a judgment largely insulated from judicial review by reason of being discretionary. Applying the de novo standard, the court could not determine whether the employee’s disability claim was justifiably rejected on the basis of the surveillance video and the likelihood of symptom embellishment, particularly relating to her right arm.
Judgment vacated; case remanded with directions.
If you need assistance navigating your claim for short term or long-term disability benefits under ERISA, or it is time to sue the insurance company, please do not hesitate to give Cody Allison & Associates, PLLC a call (844) LTD-CODY, (615) 234-6000. or send us an e-mail Cody@codyallison.com. We provide representation nationwide and have successfully sued all the major insurance companies in many states. Our headquarters are located in Nashville, Tennessee. We offer a free consultation and would love to speak with you.
by Cody AllisonColby v. Union Sec. Ins. Co.
In this 2013 ERISA case, the plaintiff claimant exhausted her administrative appeals and brought suit against defendant long term disability plan administrator. The parties cross-moved for judgment on the record and the United States District Court for the District of Massachusetts deemed the administrator’s termination of benefits unreasonable. The administrator appealed.
The central question was whether, in addiction context, a risk of relapse could be so significant as to constitute a current disability. Although its decision created a circuit split, the instant court answered the question affirmatively. A risk of relapse into substance dependence – like a risk of relapse into cardiac distress or a risk of relapse into orthopedic complications – could swell to so significant a level as to constitute a current disability. The holding was narrow. It pivoted on a fusion of the plain language of the plan and the administrator’s all-or-nothing approach to its benefits determination. The administrator could have written into the plan an exclusion for the risk of relapse, but it did not choose to do so. Without such a written exclusion in place, the administrator acted arbitrarily and capriciously in refusing to consider whether the claimant’s risk of relapse swelled to the level of a disabililty. A benefits determination could not be reasoned when the plan administrator sidestepped the central inquiry. Further, the district court did not abuse its discretion in awarding retroactive benefits. It already had remanded the case once, to no avail.
The district court’s decision was affirmed.
If you need assistance navigating your claim for short term or long-term disability benefits under ERISA, or it is time to sue the insurance company, please do not hesitate to give Cody Allison & Associates, PLLC a call (844) LTD-CODY, (615) 234-6000. or send us an e-mail Cody@codyallison.com. We provide representation nationwide and have successfully sued all the major insurance companies in many states. Our headquarters are located in Nashville, Tennessee. We offer a free consultation and would love to speak with you.
by Cody AllisonSloan v. Hartford Life and Accident Ins. Co.
In this 2006 ERISA case, the appellant insurer challenged the U.S. District Court’s determination that the appellee injured party qualified for long-term disability benefits under a plan governed by ERISA. The court first addressed the insurer’s argument that the district court abused its discretion in admitting evidence outside the administrative record. As to the duplicative medical evidence, it held that the district court did not abuse its discretion. As for the nonduplicative new evidence considered, two reasons given by the district court were sufficient to support its decision, i.e., the social security definition of disability was very similar to the definition in the plan, and the district court considered the administrative law judge’s credibility determinations regarding the subjective complaints of pain to be highly probative of the ultimate question of disability. The court turned next to the finding that the injured party qualified for LTD benefits. Under the clear error standard, there was enough evidence to support the findings. Finally, because there was simply no legitimate basis for the insurer’s contention regarding a potential offset of social security benefits at a point in time earlier than January 2001, the district court committed no error when it failed to remand the case to allow the insurer the first opportunity to calculate the offset administratively.
The district court’s decision was affirmed.
If you need assistance navigating your claim for short term or long-term disability benefits under ERISA, or it is time to sue the insurance company, please do not hesitate to give Cody Allison & Associates, PLLC a call (844) LTD-CODY, (615) 234-6000. or send us an e-mail Cody@codyallison.com. We provide representation nationwide and have successfully sued all the major insurance companies in many states. Our headquarters are located in Nashville, Tennessee. We offer a free consultation and would love to speak with you.
by Cody AllisonHampton v. Reliance Std. Life Ins. Co.
In this 2014 ERISA case, where a claimant was diagnosed with insulin-dependent diabetes mellitus, a claims-review fiduciary did not abuse its discretion under ERISA by denying his claim for long-term disability benefits. It was reasonable for the fiduciary to interpret the plan to require that the claimant show that the injury or sickness itself, independent of the loss of license, rendered him unable to perform his occupation. Substantial evidence supported the fiduciary’s determination that the claimant was not totally disabled because although his physician opined that the claimant would be unable to work as an over-the-road truck driver based on the Department of Transportation’s regulations, he identified no physical limitations on the claimant’s ability to do so as a direct result of his diabetes.
Judgment reversed, fee award vacated.
If you need assistance navigating your claim for short term or long-term disability benefits under ERISA, or it is time to sue the insurance company, please do not hesitate to give Cody Allison & Associates, PLLC a call (844) LTD-CODY, (615) 234-6000. or send us an e-mail Cody@codyallison.com. We provide representation nationwide and have successfully sued all the major insurance companies in many states. Our headquarters are located in Nashville, Tennessee. We offer a free consultation and would love to speak with you.
by Cody AllisonRote v. Titan Tire Corp.
In this 2010 ERISA case, the Appellate pan administrator appealed from the U.S. District Court for the Southern District of Iowa, which held that the administrator abused its discretion in denying appellee employee’s application for long-term disability benefits. The district court also awarded the employee attorney’s fees incurred from the date she filed her original suit in district court.
The court agreed that the administrator abused its discretion in denying the employee’s application for long-term disability benefits under ERISA. The administrator’s sole reason for denying the employee’s application was that she had not shown her disability to be “permanent.” To reach that conclusion, the administrator interpreted doctors’ letters as suggesting that the employee’s restrictions were not permanent, focusing on the use of the term “indefinitely” and relying on one dictionary definition of “indefinite.” However, the court ruled that the intended meaning of “indefinitely” — that the restrictions were permanent — was clear from the context of the letters that the employee’s attorney and the doctors exchanged. The court found no abuse of discretion in the district court’s decision to award attorney’s fees pursuant to the statute. The administrator relied on a hypertechnical reading of the medical evidence and ignored the doctors’ attempts to clarify their opinions. Additionally, there was evidence that the administrator attempted to frustrate the employee’s ability to move the claims process forward.
The judgment of the district court was affirmed.
If you need assistance navigating your claim for short term or long-term disability benefits under ERISA, or it is time to sue the insurance company, please do not hesitate to give Cody Allison & Associates, PLLC a call (844) LTD-CODY, (615) 234-6000. or send us an e-mail Cody@codyallison.com. We provide representation nationwide and have successfully sued all the major insurance companies in many states. Our headquarters are located in Nashville, Tennessee. We offer a free consultation and would love to speak with you.