Articles Posted in Recent Successes for our clients

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Insurers are still permitted to include “pre-existing” limiting provisions in its disability policies. Cigna policies provide that ” The Insurance Company will not pay Disability Benefits for any period of Disability caused or contributed to by, or resulting from a Pre-Existing Condition.” A “Pre-existing Condition” means “any Injury or Sickness for which medical treatment, care or services including diagnostic measures, prescription drugs or medicines was recommended or received from a licensed medical practitioner within 3 months before the Employee’s most recent effective date of insurance.” Cigna has a pattern of discriminating against women suffering from breast cancer. See ABC news report from 2009. They again committed bad faith in 2014 when they applied the pre-existing provision to our client, Ann-Marie, denying her bona-fide claim for disability due to metastatic breast cancer.

In 2007 Ann-Marie was diagnosed with breast cancer during a routine mammogram. She underwent surgery and chemotherapy and returned to work. For the next six years, she saw her doctor for bi-annual cancer screening and received monthly adjuvant hormonal therapy purely as a preventative measure, because the breast cancer had a large number of estrogen receptors. The treatment reduces the body’s own production of estrogen. Ann Marie changed jobs last year and received new group long term disability benefit coverage with Cigna.

Our client had symptoms of metastatic cancer four months after she began her new employment and Cigna denied the claim, asserting that her treatment of Zoladex in the three months pre-employment qualified as “treatment for cancer”.

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We are often faced with dealing with a claim administrator who services a self-insured plan. A recently published case highlights the issues that arise and is useful precedent for the cases we handle for our New Jersey disability clients. In this case, May v. AT&T, AT&T retained Sedgwick to perform the claims handling on its behalf and even made the decisions of which disability claims to pay. At&T defended its role in the claim, since it delegated all claims making decisions to Sedgwick, it believed would serve as a buffer from exposure for bad faith decision making. Many courts have held that a plan cannot be liable for arbitrary decision making that is influenced by the money saved by denying claims, if a separate claims administrator makes all of the decisions.

Here, however, the court saw through this house of cards. Sedgwick was the ERISA claims fiduciary. The court held that the actions of Sedgwick showed that Sedgwick demonstrated more loyalty to the funding entity which had employed it, than to its cestui que trust during the administrative process. The court noted “Sedgwick jealously guarded its client’s money, ” commenting, “This is one of the most bothersome aspects not only of this case, but of ERISA benefits cases in general.” Ms. May was faced with the unenviable task of appealing to Sedgwick each denial. “She hit a stone wall each time.”

The Court was particularly interested in considering whether it would be appropriate to remand the case to Sedgwick to reconsider the ongoing claim. They determined, ” if Sedgwick were ordered to take another look at the claims in light of favorable SSA decision Sedgwick could and probably would treat the SSA findings as simply something else to discount in comparison with its “independent, non-examining medical experts.” Assuming the court had the power to remand the case to the Sedgwick Briar Patch, that Briar Patch is one in which Sedgwick is accustomed to navigate.”

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Just recently, Bonny G. Rafel was successful in an appeal for a New Jersey woman who suffers from multiple conditions primarily associated with Crohn’s Disease and the treatment necessary to treat this serious condition. MetLife Insurance Company denied her claim for Crohn’s Disease. We knew that in order to succeed on her behalf, we would have to convince MetLife that the cumulative effect of her conditions and treatment impaired her ability to reliably function in any work setting full time. We coordinated our personalized efforts with her doctors who supported her claim and willingly completed our custom designed questionnaires to demonstrate that the treatment for her condition had actually caused some of the symptoms that now impair her. This includes Secondary Adrenal Insufficiency , a condition which often results from the long-term steroid regimen that accompanies treatment for Crohn’s disease. Thanks to the help of her treating doctors, we were able to convince MetLife to reverse the denial just one week after submitting her appeal.

At Bonny G. Rafel we establish a good working relationship with our client’s treating doctors to facilitate the exchange of information the insurance company is often lacking during their initial review.

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Recently, I met with a 59 year-old medical professional who had been battling a degenerative muscular disease and was contemplating filing for disability benefits after years of battling through pain and limitations on the job. Despite the fact that his condition left him constantly having to send clients out to others in his field, this professional was reluctant to file for disability insurance because his experience in the field left him wary of the procedural hurdles the insurance company would throw in his way should he decide to make a claim for his rightful benefits. Even more shocking was that he was hesitant to make a claim despite paying eighteen plus years’ worth of premiums.

Our team of lawyers and paralegals sat with him and together we prepared his submissions to the insurance company. He now enjoys the peace of mind that his claim has been approved, his life long professional practice ended respectfully and he has our firm as his liason with the insurance company so that he can focus on improving his health and daily life as much as possible.

If this story sounds like your own, don’t let the fear of procedural hurdles and insurance company tricks prevent you from getting what is rightfully yours. Remember, this isn’t charity, these are benefits that you rightly deserve, and even more importantly, have been paid for. If the prospect of dealing with insurance companies has left you wary of filing a claim for benefits even in the face of a disabling condition, hire a professional who has experience that will impact the outcome of your claim. A qualified attorney can take care of all the hurdles and roadblocks the insurance company puts up for you and make sure that you get the benefits and the quality of life that you deserve. Check our website, Bonny G. Rafel LLC

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Ms. Rafel recently won an administrative appeal filed on behalf of her client suffering from Parkinson’s Disease. Prudential Insurance Company had denied benefits claiming that there was no proof that the physical symptoms were so disabling as to render him unable to work as a retail stock broker. Prudential relied solely on its own medical consultant and nurse to support their case. Rafel pointed out her client’s problems controlling his movement as well as the cognitive deficits that have affected his critical judgment skills and ability to recall. Rafel documented that medications for the Parkinson’s Disease symptoms caused side effects that contribute to his inability to work. She elicited the cooperation of her clients’ treating doctors, including Susan B. Bressman, MD a board certified Neurologist who specializes in movement disorders at the Department of Neurology at Beth Israel Hospital in New York City. Each doctor completed comprehensive questionnaires that Rafel staff formulated to respond to Prudential’s review. Thankfully, benefits will now resume and hopefully continue until this client reaches the age of 70.

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Bonny G. Rafel announces that she recently convinced US Life to reinstate the Business Overhead Insurance benefits to her client, an orthopedic surgeon, after denying benefits on the basis that he can still perform the duties of an orthopedist in an office based setting. The insurance policy was issued through the American Medical Association, and provides important business overhead expense insurance coverage to doctors who become unable to perform the material and substantial duties of their occupation due to disability. The company determined that the doctor was not totally disabled but only residually disabled, which did not obligate them to pay the benefits. Ms. Rafel argued that the specialty practice of her orthopedic surgeon client was conducting surgery and his inability to perform this crucial task qualified him for benefits, even though he could continue with his office practice and his income may not be affected.