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Author: Seltzer & Associates

Persons Who Cannot Sit for More Than Four Hours Per Day Cannot Perform Sedentary Work, Says Ninth Circuit

Nov 11, 2016 in Articles by

In a November 4, 2016 ruling, The Ninth Circuit Court of Appeals reversed a Central District of California ruling when it concluded an individual who cannot sit for four hours a day cannot perform sedentary work. In 2011, Avery Armani suffered a back injury while at work. He was covered under a group long-term disability insurance policy issued by Northwestern Mutual provided by his employer. Following his back injury, Mr. Armani sought treatment from chiropractors, pain specialists, and physicians. Each treatment provider confirmed Mr. Armani was not capable of sitting more than four hours per day because of his lumbar […]

Third Circuit Reminds Disability Claimants to See the Doctor

May 23, 2016 in Articles by

Orthopedic Surgeon John Duda filed a claim for disability benefits with The Standard for his long-term disability (“LTD”) benefits and Lincoln for his individual disability benefits due to a wrist injury. Both Standard and Lincoln determined Dr. Duda did not qualify for disability benefits under each of his policies. However, each company cited different reasons for their decisions. Following the denial of disability benefits by each company, Dr. Duda sued each Standard, under federal ERISA law, and Lincoln, under Pennsylvania breach of contract and bad faith law, for disability benefits. The United States District for the Eastern District of Pennsylvania […]

3rd Circuit Vacates District Court Summary Judgment Opinion in Favor of Sun Life Over Discretionary Language Dispute

Mar 24, 2016 in Articles by

The United States Court of Appeals for the 3rd Circuit recently vacated the summary judgment opinion of the District Court of New Jersey in Baker v. Sun Life and Health Ins Co. Following Sun Life’s denial of continued long-term disability benefits, Kenneth Baker filed suit against Sun Life in New Jersey District Court. At conflict was whether Mr. Baker’s policy of disability insurance contained language granting discretionary authority to Sun Life in determining whether to award Mr. Baker disability benefits. If the policy contained discretionary language, a court could only review Sun Life’s decision under the arbitrary and capricious standard […]

First Circuit Requires Plan Administrators to Include Time Limitations for Civil Actions in Denial Letters

Mar 21, 2016 in Articles by

A plan participant sued MetLife claiming an improper denial of his long-term disability benefits under ERISA. Participant Dionisio Santana-Díaz was a financial analyst at Shell Chemical and a participant in the company’s employee welfare benefit plan issued by Metropolitan Life Insurance Company (“MetLife”). Mr. Santana-Díaz suffered from major depression, high blood pressure, asthma and various other physical and mental conditions and stopped working. He received sick leave and then short-term disability benefits. After being out of work for five months, Mr. Santana-Díaz submitted his claim for long-term disability benefits and was eventually awarded LTD benefits. About a year and a […]

Long Term Disability In The News – Continued

Mar 2, 2016 in Articles by

The U.S. District Court for the Northern District of Texas, on February 19, 2016, granted in part and denied in part Dewayne Curtis’ motion to compel discovery from MetLife. While discovery in ERISA actions is generally limited, in this case, the court required MetLife to answer some of Mr. Curtis’ questions in the form of interrogatories. The court required MetLife “to more fully describe the policy and methods used to determine compensation for the claims and appeals specialists who handled Plaintiff’s claim, such as any policy or method for determining and calculating bonuses, pay increases, or gain sharing.” However, MetLife […]

Long Term Disability In The News

Feb 22, 2016 in Articles by

The United States District Court for the Eastern District of Kentucky on February 12, 2016 found Aetna arbitrarily and capriciously terminated Scott Bishop’s ERISA-governed long-term disability benefits. Mr. Bishop stopped working in February 2012 due to “diffuse osteoarthritis and swelling in his joints, gout, and degenerative joint disease in his left knee.” Based upon his physical conditions, Mr. Bishop applied for his Aetna LTD benefits and Social Security (“SSA”) disability benefits. Social Security had Mr. Bishop examined by Dr. David Winkle, who authored a report on Mr. Bishop’s condition. Aetna quickly determined Mr. Bishop was not entitled to LTD benefits. […]

Recent Developments in the Law for December 28, 2015

Dec 28, 2015 in Articles by

Sobhani v. Reliance Standard Life Ins. Co. The Second Circuit, on December 18, 2015, affirmed the District Court of Connecticut’s summary judgment ruling in favor of Reliance Standard Life Insurance Company (“Reliance”) in Jeffrey Sobhani’s action for disability benefits under the Employee Retirement Income Security Act of 1974. In a brief Summary Order, the court quickly explained disability benefit determinations are reviewed under a de novo standard of review. Except “when, as in this case, written plan documents confer upon a plan administrator the discretionary authority to determine eligibility, de novo review does not apply; rather, we will not disturb […]

The 10 Most Damaging Myths About Alcoholism

Sep 1, 2015 in Articles by

In this month’s edition of the Missouri Physicians Health Program’s newsletter, Shelby Hendrix described The 10 Most Damaging Myths About Alcoholism: The Only Way to Get Better is to Hit “Rock Bottom” Drinking Culture is Harmless “You have a job, you’re not an alcoholic!” Willpower Alone Can Stop Addiction Controlled Drinking is Possible Everything will be Perfect Once You Stop Drinking Treatment is the Magic Cure Alcoholics Must go to AA Sobriety is Boring Getting Sober is Impossible To learn more about each of these myths, read the September 2015 Newsletter of the Missouri Physicians Health Program.

Sixth Circuit Reverses District Court Ruling Affirming a Partial Denial of ERISA Long-Term Disability Benefits

Aug 24, 2015 in Articles by

Melissa McKenna worked as an Administrative Assistant at Dow Corning Corporation where she received Long-Term Disability (LTD) group coverage provided by Aetna Life Insurance Company (Aetna). Ms. McKenna suffered from low back pain for many years, with a bulging disc first revealed in a 2010 MRI. Even with a bulging disc, Ms. McKinna continued to work until March 2012, when she was admitted to the hospital with a high pain level. Ms. McKinna was admitted again in April 2012 and began a treatment regimen with a pain management clinic, surgical injections, physical therapy, and treatment with a neurosurgeon, rheumatologist, physical […]

Virginia Medicaid Plans To Abandon DSM-5

Jun 22, 2015 in Articles by

WHAT EFFECT WILL THIS HAVE ON MEDICAL PROVIDERS? Virginia Medicaid has announced it plans to abandon DSM-5 in October when the switch from ICD-9 to ICD-10 diagnostic coding takes place. Virginia is the first state to announce such a move. It will be interesting to see if this move causes other states to do the same, and the subsequent affect this has on all medical providers. Read more from Behavioral.net Related Articles BREAKING: Virginia Medicaid abandons DSM-5