Priscilla & the Turf War [Video]
Updated: Jul 23, 2019
Priscilla worked her entire adult life as a nursing assistant. She bathed, fed, moved and assisted struggling patients. It was a physically demanding job. She began having problems with her neck but continued to work because she had to. It grew worse. She was placed on modified and restricted light duty. Her condition worsened. She had fusion surgery. But, she had constant pain from her neck to her hands. She ultimately filed a claim through her employer’s benefits department for long-term disability. Priscilla was only 57 years old.
Her claim was approved finding that she was disabled as to her own occupation. Payments continued for about two years. The long-term disability insurance company informed her that after 24 months she would have to prove disabled from performing any occupation, a more difficult standard.
Because Priscilla was not skilled in performing any other occupation, had severe pain, and was soon turning 60, she did not think this would be a problem. She had no typing or computer skills. She could not use her hands for more than a few minutes before the pain became severe. She thought the people at the long-term disability insurance company were really nice on the phone, so surely they would agree there was no other work she could do.
Never underestimate the economic incentive for a long-term disability carrier to terminate benefits! They make money collecting premiums. They lose money paying benefits. Initially, the long-term disability carrier agreed that she was disabled from performing any occupation, but then one week later, it reversed itself claiming that there were several occupations she could perform. Her benefits were cut off!
This created a financial hardship for Priscilla. She was waiting for her Social Security disability claim to be approved and she could not work. She had to fight to survive.
Priscilla called us. We reviewed her claim history. We explained that she should eventually obtain Social Security disability benefits. However, that would greatly reduce the value of her long-term disability benefit (due to a common provision in her LTD policy which reduces its benefits by any Social Security benefits). Once her Social Security disability benefit was paid there would be very little at stake to make her case financially feasible for us on a contingent fee basis. We could see the desperate look in her eyes. We were her only hope. We knew that without a lawyer, her appeal would be likely be denied by the long-term disability.
While the provisions of ERISA are often used by carriers to their benefit, it is our turf too. We agreed to take her case. We prepared a thorough appeal. We presented it to the long-term disability insurance company. It reversed its decision and agreed to pay the claim! Priscilla was thrilled.
The thrill of victory would be short-lived. After a few months of benefits, a new adjustor took over Priscilla’s claim. He terminated her benefits.
Priscilla’s circumstances and conditions had not changed. She had the same problems. She still had not received her Social Security and she could not work. What changed? Nothing but the adjuster.
Frustrated by the inconsistent decision-making (which appeared to be a pattern), we planned an appeal. We obtained the claim record and more information from her treating doctors. We prepared an extensive appeal. The insurer dug in refusing to pay the claim.
Meanwhile, the Social Security Administration finally awarded Priscilla her Social Security disability benefits. As a result, the value of her long-term disability case plummeted. Priscilla wanted to pursue her appeal because the insurance company had been so unfair. We agreed. If we did not continue the fight, the insurer would have no incentive to discontinue its abusive conduct. We filed a lawsuit. The decisionmakers at the insurance company quickly saw the wisdom of settling the case.
Our fee was insignificant. Most lawyers would not have taken that case. But it wasn’t about the fee. People like Priscilla should not be treated like she was. Unfortunately, this is all too common with ERISA. That is where our experience and focus on this area of law comes into play. Our knowledge and determination allows us to help those who are treated unfairly.
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