A Psychiatric Disability Case Gone Wrong For AT&T
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Here's a great case out of Tennessee in which the insurance doctor made a decision to deny with hardly any information. That's dangerous because what if they then miss information that makes it an obviously valid claim? Well then they get sued and taken to court and that's exactly what happened.
It was a psychiatric disability case and those are tricky and require a bit more attention from the disability insurer. Dr. Grimes, the reviewing psychiatrist made the decision to deny based on the opinion that the claimant was able to perform her job. She made that decision without any knowledge of the claimant's job, without interviewing the claimant, and without consulting with all of the claimant's treating mental health professionals.
That might fly in physical disability cases because often the records can speak for themselves, but when they're dealing with psychiatric disability it's important to have a physician actually meet with the claimant to determine the extent of the disability. Unfortunately that's not how the insurance companies want to do it, so they don't. Trying to save a little time and money and they're asking for litigation. Well, again, they got it. Next time they should take the time to actually review the claim and save everyone the hassle of court by accepting the initial claim.
Click here to read the full opinion of Allen v. AT&T Disability Income Program, the case in question.
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Another Court takes MetLife to Task for its disability reviews
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Disability FAQ - More Answers To Your Questions
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Court takes Prudential Insurance Company to task in disability claim.
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Posted on Mar 24, 2008
Graham Harrison, suffered from Tourette Syndrome which prevented him from working on a full time basis. He applied for partial disability benefits under a disability insurance policy his employer had with Prudential Insurance Company of America. His treating physician, a neurologist and specialist in Tourette Syndrome had recommended that he consider reducing his work schedule to less than full time to accommodate his condition which have led to chronic anxiety, a disrupted sleep pattern and agitation. His doctor felt that a four day work week with a mid week break would benefit him immensely.
Prudential denied the request for benefits. Prudential's position was that since he had suffered Tourette's Syndrome for many years his records did not document a significant recent change that would warrant a change in his work patterns. Prudential also felt that if he could work four days there was no reason that he could not work five days in a week.
At first Prudential relied on the opinion of its "medical director", Jill C. Fallon, M.D., a doctor who was Board Certified in occupational medicine but had absolutely no expertise in neurology or Tourette's Syndrome. This doctor did not even examine the claimant.
Prudential also looked at the wrong definition of disability in denying the claim.
Mr. Harrison appealed the denial of benefits and included additional reports from his well qualified physicians. On appeal, Prudential showed the file this time to Albert Kowalski, M.D. another one of its employed physicians. Not only did Dr. Kowalski not have Board Certifications in neurology or psychiatry, he had absolutely no experience in the treatment of Tourette Syndrome and indeed had not had any clinical practice since 1987. Dr. Kowalski did not examine the claimant. Despite the lack of qualifications and any current experience in actually seeing patients, Dr. Kowalski was of the opinion that the claimant's condition should have improved over time.
On the basis of Dr. Kowalski's opinion, Prudential denied the claim. In denying the appeal Prudential once again quoted the wrong definition of disability. The plaintiff again appealed and this time consulted with yet another expert in Tourette Syndrome. He was evaluated by Oliver Sacks, M.D. a clinical professor of neurology at Albert Einstein College of Medicine and an adjunct professor of neurology at the New York University School of Medicine. Dr. Sacks had authored numerous books and articles on Tourette Syndrome. It was Dr. Sacks' opinion that Mr. Harrison could maintain his effort and function very effectively for only two days at a time and then must take a break of a day to recover. He cannot function on a "standard" five day week. On the basis of this letter Prudential reversed its original decision and awarded benefits to the plaintiff. Prudential however continued to misstate policy provisions and indeed quoted language that appeared nowhere in the plan.
Two months after approving the claim Prudential began re evaluating the claim. This time Prudential took the position that the plaintiff's disability was caused at least in part by a mental psychoneurotic or personality disorder and that benefits were limited to 24 months. Prudential advised the claimant that his claim would most likely terminate the next month.
The problem with Prudential's denial of benefits this time was that there was no 24 month limitation in this policy.
Prudential also referred the file to Stephen N. Gerson, M.D. Dr. Gerson was Board Certified in psychiatry and geriatric psychiatry but listed his major professional activity as "administration." There was no evidence in the file that Dr. Gerson had any experience in the treatment of Tourette's Syndrome. He did not examine the claimant. It was Dr. Gerson's opinion that the various treating physicians and the claimant himself were simply making a "preference" for not working a five day work week. Shortly thereafter Prudential terminated benefits yet again.
Mr. Harrison filed suit under ERISA.
The court reversed Prudential's denial. The court found that "In the worst light, such conduct [misquoting policy provisions] indicates a conscious attempt on the part of Prudential to manufacture a reason for denying plaintiff benefits."
The court also found that the decision to terminate benefits was not supported by substantial evidence. The court said that Prudential had ceased on one piece of information that one of the doctor's had relayed to it to terminate benefits. The court found that Prudential had not relied on any new information to terminate benefits after it had previously approved benefits on the same information. The court also was critical of Prudential for using doctors who had no expertise in Tourette Syndrome and who never examined the claimant.
Fairfax, Virginia attorney Ben Glass represents doctor, dentists, lawyers and business executive in long term disability benefit claims.
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Disability Insurance - Q & A
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Claimant Wins CIGNA Cardiac Disability Case
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Disability Insurance Company Knew All Client's Golf Scores for last 5 years
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Got an interesting call recently. A client who is a medical surgeon who's disability involves fine motor skills still plays golf. (That's OK, hitting a golf ball into the woods does not compromise patient safety!0
He has a claim with a major disability insurance company. The field rep came around for a visit and asked about golf. The client answered appropriately and truthfully.
The disability investigator said "that's exactly what all these golf scores say!"
Pretty scary stuff. Your life is an open book.
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Disability Insurance Info
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How Should A Judge Assess Disability?
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Florida Disability Attorney Nancy Cavey Says Unum's Reversal Rate Almost 50%
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Judge Attacks University Disability Consortium's Advertising and Policies
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The University Disability Consortium (UDC) gets hired by insurance companies to independently review medical claims. They advertise that their service will most likely result in "improved denial and closure rates at a reduced cost."
Translated: "If you hire us, we will deny claims to save you money."
And they'll do it in a plethora of ways. In the case of Velikanov vs. Union Security Insurance, UDC's Dr. Brian Mercer used the "close-enough" method. As in he addressed a condition that the claimant didn't have, but hey, the condition he wrote about and the condition the claimant had (two different types of cysts) were "close enough" that they could be misconstrued by anyone without a medical degree. Either he's not doing his job right (misreading files) or he IS doing his job right (finding ways to deny legitimate claims).
The judge basically threw out Dr. Mercer's opinions because he found them to be "inherently bias." I have a feeling that that term could be applied to most if not all insurance docs but as of now it seems their pseudo-medical opinions are still generally accepted in the courtroom. Read more on Velikanov vs. Union Security and see how UDC gets scolded.
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More Disability Q&A - Ask And I Will Tell
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Threats by Disability Insurance Company
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I've got a potential client who may have a claim against one of the major long term disability insurance companies for lifetime benefits. (Yes, these policies exist--written long ago...collected premiums all these years...they just hate it when a claim is made)
Anyway, the claims rep tells him "you know, if you make this claim we are going to bug you and pester you for the rest of your life. We'll not only require every form known to man but you'll never know when the truck down the street is hiding our video surveillance."
The potential client, to his great credit, didn't take the bait and argue with the guy.
He just said: that's exactly what Ben Glass told me you would say!"
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Lincoln National Misinterpreted Its Own Disability Policy Says Federal Judge
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Another court MetLife takes to task for his disability evaluations
Court prudential insurance company has a process in a disability claim.
Posted on the Mar 24, 2008
Graham Harrison, suffered from Tourette's syndrome, that it prevented work on a full-time basis. He applied for partial disability benefits under his employer with prudential insurance company of America was a disability insurance policy. His physician a neurologist and expert on Tourette Syndrome had recommended that he work at less than full time resources have led his schedule to place for his condition, to chronic anxiety, a broken sleep patterns and excitement. His doctor felt that a four day work week with a mid week break it would immensely benefit.
Prudential pointed out that Please back benefits. Prudential's position was that, since he had suffered his records Tourette Syndrome for many years the youngest documented no major change, which would justify a change in his work patterns. Prudential also felt that if he could work four days there was no reason that it five days not could be working in the week.
On the first prudential relied on the opinion of the "Medical Director" Jill C. Fallon, m.d., a physician, was board certified in occupational medicine but had absolutely no training in neurology or Tourette Syndrome. This doctor does not even tested the plaintiff.
Prudential have also with the wrong definition of disability in the right to deny.
Mr Harrison appealed the denial of benefits and include additional reports from his well qualified doctors. On appeal, one of his employees showed doctors prudential of the file of this time, Albert Kowalski, m.d.. Not only Dr. Kowalski had no Board certification in neurology or Psychiatry, he had absolutely no experience in the treatment of Tourette Syndrome, and in fact had no clinical practice since 1987. Dr. Kowalski did not examine the claimant. Despite the lack of qualifications and current experience in really patients seen was Dr. Kowalski of the opinion that should have improved condition of the claimant in the course of time.
On the basis of the opinion of Dr. Kowalski, prudential denied the claim. To deny the appeal, prudential again cited the wrong definition of disability. The claimant appeal again and this time consulted with yet an expert in Tourette Syndrome. He was Clinical Professor of Neurology at the Albert Einstein College of medicine and associate professor of Neurology at New York University School of medicine evaluated by Oliver Sacks, m.d.. Dr. sacks had was author of numerous books and articles on Tourette's syndrome. It was Dr. sacks opinion that Mr Harrison was able to maintain its efforts and function very effectively for only two days in a row and then a one day break to recover. He can not work on a "standard" five-day week. This letter of prudential undone by its original decision and awarded the plaintiff benefits. Prudential but still inappropriate policy provisions and language in fact cited, which nowhere appeared in the plan.
Two months after approval of the claim of prudential re review of the claim started. This time, prudential took the position that the plaintiff disability psychoneurotic at least in part by a mental disorder or personality was caused and that benefits are limited to 24 months. Prudential advised the plaintiff that its request would most likely end next month.
The problem with the prudential was denial of the benefits of this time, that there no 24 month limit in this directive.
Prudential is also the file Stephen N. Gerson, m.d. Dr. Gerson has board certified in psychiatry and geriatric psychiatry but listed important professional activity as a "Web management". There was no evidence that Dr. Gerson had no training in the treatment of Tourette Syndrome in the file. He did not examine the claimant. It was Dr. Gerson believes that the various doctors and the applicant simply did a "preference" for the work of any five-day week. Shortly after prudential terminated benefits once again.
Mr Harrison action under ERISA.
The Court reversed denial-of-prudential's. The Court found that "in the worst light, such behavior [misquoting policy provisions] a conscious attempt by prudential a reason for the plaintiff benefits production are."
The Court also ruled that the decision to terminate the benefits was not supported by sufficient evidence. The Court said that some of the information of prudential had ended, that the doctor in benefits cancellation had delivered one. The Court found that prudential had not left to stop benefits after it had previously approved benefits on the same information to all the new information. The Court was also for use by physicians, who examined no experience in Tourette Syndrome, and never, the the plaintiff, prudential critical.
Fairfax, Virginia provides lawyer Ben glass doctor, dentists, lawyers and businessman in long term disability benefit claims.
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Disability insurance - Q & A
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Judge attacks University disability Consortium advertising and guidelines
Translated: "If you hire us, we claim for money to save denied."
And she will do it in a variety of ways. In the case of Velikanov vs. Union security insurance used UDC by Dr. Brian Mercer "enough close" - method. As in a condition which the plaintiff not but hey, mentioned, the of, wrote it about the condition and the condition of the plaintiff had (two different types of cysts) were "close enough", that they each without medicine to emission determined be could. Either he is not his job right (misinterpretation files) or IS doing his job right (search for ways to the legitimate claims to deny).
The judge threw reviews basically from Dr. Mercer because he found it too "inherently influenced." I have a feeling that this term to, if not all insurance docs could be applied, but now it seems their pseudo-medical opinions still generally accepted most of in the courtroom. Read Union at Velikanov vs. Security and see how UDC gescholten calls.
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Disability insurance company knew all client golf scores for the last 5 years
He has a claim with a large disability insurance company. The field rep to visit around came and asked golf. The client answer appropriately and truthfully.
The investigator said disability ", which say exactly what these golf results!"
Pretty scary stuff. Her life is an open book.
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Threats by disability insurance company
However, claims Rep replies "You know." "If you make this claim, that we you bow and harass you for the rest of your life we will not only require each form to humans known but you never know when the truck on the street hidden, our video surveillance."
The prospect, his great merit not take the bait and argue with the guy.
He just said: that's exactly what Ben glass you would say told me! "
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