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EXCLUSIONS AND LIMITATIONS ARE THE NEW TREND IN DISABILITY INSURANCE As of October 1, 2016, nearly every disability insurance company will either exclude or limit disability insurance claims related to mental nervous and/or addiction related impairments. This applies to both Individual Disability Insurance (“IDI”) policies as well as employer sponsored group Long-Term Disability (“LTD”) insurance plans. Historically, IDI policies were issued without exclusions or limitations for mental health and/or addiction related impairments. Conversely, nearly every LTD plan issued contained less favorable coverage, such as exclusions and 24-month limitations for these impairments. Studies confirm that 25% of professionals will suffer a […]

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 […]

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 […]

As an attorney, in a practice dedicated to representing impaired professionals with individual and group disability insurance matters, I am troubled by the general lack of knowledge regarding disability income replacement insurance. My concern stems from the sobering reality that more than 1-in-4 of today’s 20-year-olds will suffer a disabling medical condition before they retire.1 While this statistic is troubling, it pales in comparison when considering 68% of adult Americans fail to set aside money for emergencies.2 You need only reflect on your own financial situation. Take a minute. Research confirms 65% of working Americans would be unable to pay […]

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 […]

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. […]

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 […]

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.

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 […]

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