Client with Debilitating Knee Injury Awarded $247K Settlement for Wrongfully Denied Long-Term Disability Benefits

When a client with serious knee surgery complications was denied a long-term disability claim from one of the nation’s largest insurance companies, Michael Horrow and the team at Donahue & Horrow LLP were able to secure a very favorable settlement to help the client focus on his recovery. 

In December 2017, after a lifetime of hard work, our then 58-year-old client was forced to stop working after his third knee surgery, due to complications from a revision of a prior left total knee replacement.  While our client had been able to return to work after his prior surgeries, he never fully recovered from his third knee surgery.  He turned to his long-term disability carrier and filed a claim for disability benefits under the ERISA-governed benefit plan provided by his employer.  

The insurance company agreed that our client was not able to work and initially approved his disability claim.  For the next two years, our client continuously provided updated medical records to the insurance company. This included records from rotator cuff surgery and plans for a fourth left knee surgery that had to be delayed due to the COVID-19 pandemic.

After 24 months of receiving benefits,  the definition of disability changed, as is typical in ERISA-governed disability plans.  Initially, our client only had to demonstrate that he was unable to work the job that he performed at the time of his disability, that of a production manager, in order to qualify for benefits.  However, after two years, our client was required to show that he could not “perform the duties of any gainful occupation” in order to qualify for benefits.  Immediately after the change in the definition of disability, our client continued to receive monthly benefit checks.  However, after three months, the insurance company arbitrarily and suddenly denied our client’s claim— because an underqualified in-house nurse reviewer employed by the insurance company believed our client could return to work.

This led our client to approach Donahue & Horrow LLP for help with an appeal of the wrongful denial of his claim.  The Firm took over all communication with the insurance company and ensured that the insurer received all of our client’s updated medical records as well as reports from a Functional Capacity Evaluator and a Vocational Analyst further supporting the claim.

When the insurance company refused to reverse its claim decision on appeal, Donahue & Horrow LLP filed an ERISA complaint in the United States District Court for Central District of California’s Los Angeles courthouse.  Eventually the parties conducted a mediation, during which the insurance company agreed to pay our client a substantial settlement in exchange for a dismissal of the lawsuit.  With the settlement, our client was able to avoid the uncertainties inherent in litigation and was also freed from having to make monthly reports to the insurance company regarding his medical condition.  Now, using the money from his settlement, along with his monthly Social Security Disability Insurance benefits, our client is able to spend his time focusing on his recovery and spending time with his family, rather than fighting with the insurance company.

If you believe your disability insurance, life insurance, AD&D or long term care insurance claim was improperly denied by your insurance company, call Donahue & Horrow LLP at (877) 664-5407 for a free consultation.