Long term Disability

In nearly all group disability insurance policies, the disability definition changes to an “any occupation” standard typically after typically24 months. This standard seems equivalent to Social Security, but is considerably more complex. The insurance definitions can vary based on earnings qualification and the degree of skill transferability. Bartolic Law leads the industry in demonstrating insurers incorrectly apply these changed definitions, either due to overstating your physical abilities or overstating the skills you employed in your prior work. In one client’s case, the insurer vocationally concluded it could not find an alternate occupation without the client’s physical ability to perform at the light exertion level. We suspected the insurer pressured an independent medical examiner to change her opinion, and shortly after serving the doctor with a subpoena, the insurer folded and reinstated the claim in full.

In Contreras v. United of Omaha, Bartolic Law obtained a judgment that helped our client, and thousands of others around the country, by persuading the court the insurer’s assumption a claimant can always earn at least the median wage in a substitute occupation is not credible, especially when the degree of transferability of skills is quite low. Bartolic Law has worked with the best vocational experts for so long, we can identify at the outset when the insurer’s vocational expert’s opinion lacks enough credibility to withstand judicial review. This is a small sample of our results.

In long-term disability claims where there is a diagnosis that falls under a policy’s 24-month limitation, the insurer often asserts the limitation applies, even if it is not the driving cause of the disability. Often, physical disabilities cause individuals to experience anxiety and depression secondary to the physical disability, but the insurer tries to apply the limitation. One of our clients suffered from a significant spinal disorder, and was also diagnosed with Major Depressive Disorder secondary to the physical illness (often called Adjustment Disorder). Reliance Standard threatened to terminate benefits at 24 months due to mental illness. Bartolic Law prevailed for the client, showing the client was disabled even if taking the mental health symptoms out of the equation. We obtained payment for the client in full without lengthy litigation. The client was able to maintain the client’s standard of living, with no public record of her dispute with the insurer.

Most group long term disability insurance policies broadly define pre-existing conditions to include any condition you had, received treatment for, or had symptoms of before gaining insurance coverage, even if not yet diagnosed. In a recent case, Unum applied a pre-existing condition exclusion to an executive, with a maximum policy benefit, suffering from ALS. He manifested symptoms that doctors subsequently attributed to ALS, but initially believed were lingering symptoms of an old back injury experienced on a boat. Bartolic Law persuaded the insurer the exclusion did not apply. Michael Bartolic is the most adept at arguing contract interpretation issues, and demonstrated the policy reason for these exclusions is to protect the insurer from information asymmetry and adverse selection (where someone gets insurance coverage knowing they have a claim). But where the claimant and their doctors cannot reasonably suspect the disabling condition causes the symptoms, the exclusion does not apply. The client received payment in full, maintaining the client’s standard of living, swiftly and discreetly, with no lawsuit required.

In another recent case, an investment banker long treated for ADHD with prescribed Adderall claimed disability under a Cigna policy based on depression and anxiety. Cigna asserted both that the client was not disabled, and the ADHD was a pre-existing condition barring the claim. Bartolic Law successfully persuaded Cigna the client’s depression and anxiety were disabling given the intense occupational demands, and that even taking the ADHD symptoms out of the equation, the client still met the standard for payment. Cigna respectfully agreed and paid the client in full, without us having to resort to litigation.

You will be given a short amount of time after a denial to appeal the decision. This is your only chance to fully present your case, including all evidence you want a court to be able to see if the case goes to litigation. A long-term disability appeal is a lot like preparing for a trial in 180 days or less. The sooner you involve Bartolic Law in the process, the greater the chance of success on any claim. The insurer will use every tool at its disposal to deny your claim, and try to maintain that denial. Level the playing field by getting Bartolic Law on your side.

Individual disability insurance rarely includes a changing definition of disability. But in nearly all group disability insurance policies, the definition of disability changes after some period of time, ranging from 12–60 months, from based on your own occupation to an “any occupation” definition. This standard seems equivalent to Social Security, but is actually more complex. All policies’ precise definition of “any occupation” vary based on earnings qualification of the substitute occupation and the degree of required transferability of your existing education and experience. Bartolic Law leads the industry in demonstrating insurers and plans incorrectly apply their vocational terms of this standard. In Travis v. Midwest Operating Engineers Pension Plan, we demonstrated the Trustees could not apply this standard without finding the client qualified for another occupation. In Contreras v. United of Omaha, we persuaded the court assuming a client with no experience in a field would earn the mean wage was wrong.

In long-term disability claims where there is a diagnosis that falls under a policy’s 24-month limitation, the insurer often asserts the limitation applies, even if it is not the driving cause of the disability. Every policy is worded differently, and never take an insurer’s decision on whether a limitation applies for granted. Often, physical disabilities cause individuals to experience anxiety and depression secondary to the physical disability, but the insurer tries to apply the limitation. Most importantly, do not wait until the benefits expire to challenge the limitation. Often the insurer will tell you it approved the claim under a limitation. That is your cue to contact Bartolic Law to challenge the application right away, or you could forfeit your right to benefits beyond the limitation period.

Common examples of diagnoses for which insurers try to apply a 24-month limitation include:

• Depression, Anxiety, And Other Mental Health Conditions
• Spine Disorders and Surrounding Soft Tissue
• Fibromyalgia and Chronic Fatigue Syndrome
• Any Chronic Pain Condition the Insurer Calls “Self-Reported”
• Schizophrenia, Even When The Policy Exempts It From the Limitation
• Traumatic Brain Injuries, Often Wrongly Labeled As Mental Health
• are mental health diagnoses and neuromusculoskeletal conditions, such as disorders of the spine and surrounding soft tissue.

Most group long term disability insurance policies broadly define pre-existing conditions to include any condition you had, received treatment for, or had symptoms of in the 3 months before gaining insurance coverage, even if the condition was not yet diagnosed. Bartolic Law has helped many clients defeat insurers wrongly applying this exclusion. Michael Bartolic is the most adept at arguing contract interpretation, and has successfully shown the purpose of these exclusions is to protect the insurer from information asymmetry and adverse selection, and where those concepts are not apparent, the pre-existing condition exclusion should not bar your claim.