Long Term Care Insurance

What would you do if your promising career came to an abrupt end at the age of 27 due to disability? That’s what happened to our client, who was forced to stop working at such a young age when, despite multiple procedures and countless pain injections, severe, intense pain caused by chronic pancreatitis left him unable to perform the duties of his occupation. 

Thankfully, as a benefit of his employment, his employer provided ERISA-governed group disability insurance coverage. No longer able to work, our client filed a claim for long-term disability benefits, which was promptly approved due to the overwhelming amount of evidence documenting his disability and inability to continue working. Then, two years later, when the definition of disability changed such that he was only entitled to benefits if he could not work in “any gainful occupation,” the insurance company again approved his claim.

For the next 14 years, our client provided the insurance company with unfettered access to his medical records, and after reviewing them, the insurer continued to pay and approve our client’s disability claim. Searching for a way to get out from under the obligation of paying the claim, the company ordered two days of surveillance. Not surprisingly, the very minimal activity observed (pumping gas, driving for local errands and talking to his neighbor) was blown out of proportion, with the insurer arguing that these limited periods of activity were definitive evidence that he could return to full-time light work after over a decade of being disabled, Thus, despite a complete lack of evidence of any significant improvement in his medical condition, and only four months after an internal review concluded that his claim was supported by the available evidence, the insurer suddenly denied his disability claim. 

Under ERISA, a claimant is not allowed to immediately file a lawsuit but rather must appeal the claim denial decision. Of course, the company that made the denial decision in the first place is the same company that reviews the appeal. Unsurprisingly, our client’s appeal fell on deaf ears and was denied.

After the insurer’s final denial decision, Michael Horrow and his team at Donahue & Horrow LLP promptly filed a complaint in the Los Angeles branch of the Central District of California, seeking all benefits available under ERISA and the employee welfare benefit plan.

Once in litigation, and knowing they faced a bench trial against very experienced ERISA disability lawyers, the insurance company was eager to engage the help of a mediator to attempt to end the litigation. Thankfully, the mediator was able to help the parties reach an agreed-upon settlement. While the terms of the settlement are confidential, our client is very satisfied with the outcome and even happier about no longer having to deal with the insurance company and certify his disability every month. 

If you can no longer work and your insurance company is refusing to pay you the disability insurance benefits to which you are entitled, call Donahue & Horrow LLP at (877) 664-5407 for a free consultation. Our dedicated team of ERISA disability lawyers are ready to fight for the benefits you deserve.