ERISA Denial Overturned for Pharmaceutical Admin

In the event your employer provides disability insurance coverage as a benefit of your employment (unless you worked for the government or a church-based organization) you will most likely be subject to ERISA, the Employee Retirement Income Security Act of 1974. As with many Federal laws, ERISA was drafted by Congress and is interpreted by the Courts to favor insurance companies like Unum Life Insurance Company, New York Life Insurance Company, and MetLife Insurance Company; but not so favorable to those insured by them, such as yourself.

The rules and regulations of ERISA are often used against disabled claimants through the strict application of deadlines and other requirements. For example, after a claim is denied, the insured cannot immediately file a lawsuit to obtain the promised benefits. Instead, the insured is required to file an appeal right back to the same insurance company that already denied the claim, not to an independent agency. Even worse, the appeal must be filed within 180 days and must include all of the information that might possibly support the claim as ERISA places great restrictions on the use of other evidence at trial. 

Faced with this daunting prospect, many people hire Donahue & Horrow LLP to help with their disability insurance appeals. With decades of experience litigating ERISA cases, Michael Horrow and the Firm’s team of ERISA Lawyers are well-positioned to help with your appeal. Often, our team is able to convince the insurance company to overturn their denial decision, allowing our clients to collect benefits without having to resort to filing a lawsuit.

Recently, we were hired by a Contract Administrator for a pharmaceutical company. She filed a disability insurance claim with a massive insurance company. After working for over 30 years in a career and field that she loved, our client’s chronic neck, shoulder, hip, and back pain became too overwhelming. Over the years, our client underwent four surgical attempts to relieve her pain so she could continue working. Despite these attempts, the pain became too much for her to bear. She was forced to stop working and filed a disability claim with this insurance company.

Our client provided the insurance company with her medical records, including multiple surgery records. In the records, her treating physicians supported her contention that she was unable to continue working. However, the insurance company quickly denied her claim. 

Instead of believing her treating physicians and her well-documented and diagnosed pain, the insurance company followed the opinions of their own in-house doctors and nurses that stated our client could return to work. Of course, these medical professionals never examined her, nor did they even speak with our client, but somehow, still concluded that the physicians who examined and treated her must be wrong, and she was able to get back to work.

Understanding that she was alone against a multi-billion dollar insurance company, our client contacted Donahue & Horrow LLP for assistance with her appeal. Our team helped gather her medical records, obtained further statements of support from her doctors, and compiled other evidence to support her claim, including a Functional Capacity Evaluation, a Vocational Analysis, and personal statements.

After reviewing the detailed, 40-page appeal letter and another 280 pages of exhibits our team prepared, the insurance company reversed its decision and approved our client’s claim for long-term disability benefits. In proving to the insurance company that its initial denial decision was incorrect, Donahue & Horrow LLP was able to obtain disability insurance benefits for our client immediately, without our client having to endure the process of a lawsuit.

If your claim for Disability Insurance, Life Insurance, Accidental Death & Dismemberment (AD&D), or Long-Term Care Insurance claim was improperly denied by your insurance company and you need to file an appeal, call Donahue & Horrow LLP at (877) 664-5407 for a free consultation.