Success Stories:
Tony Y. is a retail worker from Illinois who was diagnosed
with HIV/AIDS 15 years ago.
New medications for the treatment of AIDS over the years
improved his quality of life and enabled Tony to continue
working until the side effects of his medications caused severe
bowel problems accompanied with fatigue, osteoporosis, and
disorientation. Tony was forced to stop working, first by
reducing his hours to part-time, then cessation of work
entirely. Insured by MONY Life Insurance Company, he applied for
disability benefits in 1992, and was told by Disability
Management Services, Inc. to apply for Social Security
Disability. SSDI benefits were quickly awarded. Disability
benefits were paid by DMS until 2009 when the new claims
specialist began to aggressively “risk manage” Tony’s claim by
requiring multiple Independent Medical Examinations and placing
his claim on Reservation of Rights Status on a month to month
basis. Disability Claims Solutions, Inc. was hired and through a
process of advocacy involving contact with Tony’s attending
physician, HIV/AIDS advocacy groups in Illinois, and finally
state and federal legislators, Tony was able to stop DMS from
“doctor shopping” to obtain medical opinions in support of a
denial. Tony’s case might have ended in disaster with denials of
all three of his policies had he resigned himself to failure and
just given up. Fortunately, DCS, Inc. was able to provide Tony
with information concerning the claims process i.e. “the process
of stacking the deck” and enabled him to defend his case and
keep his benefits – a real success story in the area of
thwarting unfair claims practices to deny claims by DMS, Inc.
Jennifer is a 40 year old school teacher who was diagnosed
with fibromyalgia in 2001.
She applied for, and received group short-term and long-term
disability benefits. After 24 months of paid LTD benefits, her
disability insurer denied her benefits claiming she had been
paid under the mental and nervous provision of her policy and
had received the maximum benefit under the terms of her policy
which limited mental and nervous claims to 24 months. Jennifer
was devastated! As a single mother with three children, she now
had no financial assistance.In talking with Jennifer, I
discovered the insurer had never informed Jennifer they were
paying her for a mental and nervous claim. She continued to
submit proof from her primary care physician, during the first
24 months, thinking the disability insurer accepted fibromyalgia
as a “physical” impairment. She couldn’t have been more wrong.
In helping Jennifer manage her claim through the ERISA appeal,
we were able to show the disability insurer fibromyalgia is a
“physical impairment”, not a mental one. Jennifer’s claim denial
was overturned and her benefits were reinstated. Mr. Daniel X
had been a Financial Planner for nearly 20 years when he
developed Depression and Anxiety causing him to have daily panic
attacks during his customer presentations.
As time went on, he found it necessary to seek counseling and
found that he just could not perform the material duties of his
occupation. Dan had purchased three IDI policies in the mid
1980’s and trusted the income would get him through any medical
or disability emergency that came up. He was very wrong.In
working with Dan’s attorney, we were able to determine the
disability insurer had required him to submit to numerous
Independent Medical Evaluations which supported his disability.
However, the last IME (six in total) favored the denial position
of the insurance company, a practice preferred to as “doctor or
IME shopping.” This routine practice among others led the
disability insurer to offer Dan a settlement and the case was
successfully concluded. Dan is not now working as a Financial
Planner, and he received a reasonable settlement of his
Individual Disability claims after they were denied by his
insurance company. A real plus for the insured Mary Y is a
Registered Nurse diagnosed with chronic fatigue.
After receiving benefits under the provisions of her policy for
24 months, her claim was terminated when the definition of
disability changed in her contract. The disability insurer
conducted a Transferable Skills Analysis, and located
alternative occupations it believed she could perform.Upon
examination of Mary’s policy provisions, I discovered that the
definition of “gainful” in her policy was “60% of indexed
pre-disability” earnings. When I looked very carefully at the
insurer’s documentation I was able to determine the claims
specialist did not “index” the pre-disability earnings, and the
alternative occupations were in fact “not gainful.” When the
number crunch was provided to the insurance company, they
reinstated Mary’s benefits along with a letter of apology.
When a policy requires “indexing”, they need to index! I
actually discovered one of my clients’ benefits had been
significantly reduced for an estimate of social security
disability which was intended to be punitive since she refused
to apply for SSDI. Upon looking at her policy I discovered she
in fact had a “non-integrated” policy which did not allow
offsets for other income such as social security. Her disability
insurer was required to send her a check to compensate for the
error. |
