Articles Tagged with insurance denials

The short answer: Yes, depending on how much time has passed since you first submitted your claim.

Consider the following scenario. You work for a company that has an insured long-term disability (“LTD”) plan that is governed by the Employee Retirement Income Security Act of 1974 (“ERISA”). Let us say the insurance company is Prudential Insurance Company of America. You go out on disability due to chronic pain and file a claim with Prudential on July 25, 2019. On August 19, 2019, Prudential acknowledges that it received your medical records, activities of daily living questionnaire, and work capacity questionnaire. But inexplicitly, it says it needs more time to decide your claim and takes a 30-day extension. In the meantime, Prudential reaches out to your doctor to request feedback on its medical evaluation conducted by one of its nurse reviewers. Prudential also seeks clarification from you regarding your medical history. On November 13, 2019, Prudential confirms that the file is complete, but it states it needs more time to decide your claim. It does not explain why it needs more time. Finally, on November 27, 2019, Prudential decides against you. Can you file a lawsuit?

According to Judge Jeffrey White in the Northern District of California, the answer is yes. See Hasten v. Prudential Ins. Co. of Am., No. 19-CV-07943-JSW, 2020 WL 3786229 (N.D. Cal. July 6, 2020).

In early March of this year Class Notices were sent to individuals who were covered under a Blue Shield of California non-ERISA health plan during the period of September 2, 2007 through December 31, 2015, and were denied authorization or reimbursement for residential treatment of anorexia nervosa or bulimia nervosa on the grounds that their plans did not provide coverage for residential treatment.

If you are a member of this class you may submit or resubmit to Blue Shield any claims you may have for reimbursement for residential treatment that you received while a Blue Shield member between September 2, 2007 and December 31, 2015 for anorexia nervosa or bulimia nervosa if Blue Shield denied authorization or reimbursement on the grounds that your plan did not provide coverage for residential treatment. Blue Shield may not rely on any residential treatment exclusion to refuse to reimburse any new or resubmitted claim by a Class member for medically necessary residential treatment of anorexia nervosa or bulimia nervosa.

If you would like to submit a new claim or resubmit a previously denied claim, you must submit the Claim Form by September 1, 2020 to the following address:

Here at Kantor & Kantor we constantly find ourselves working closely with SSDI attorneys on behalf of our clients. Even more often, the evidence we secure on behalf of our clients during their LTD disputes can be utilized by your clients to support their SSDI claim as well. Here are some thoughts on our clients’ intersection between LTD and SSDI.

If we have a mutual client, use us as a resource to fight the substantive disability claim.

We can promptly provide copies of critical case documents, including testing or expert reports we have acquired in support of our client’s LTD fight. Our evidence saying a claimant is completely unable to work in any occupation on even a part time basis should be similarly useful for your SSDI case.

For Immediate Release

May 7, 2020

Kantor & Kantor, LLP and Dawson & Rosenthal, P.C. FILED A COMPLAINT in the United States District Court, Central District of California on behalf of their client Sovereign Health, a Gold Star Award winning healthcare provider that treated mental health, substance abuse, and dual diagnosis patients . The $1.125 billon suit alleges that Health Net, Centene Corporation, attorneys from Manatt, Phelps & Phillips, and others engaged in practices that are in violation of the Racketeer Influenced and Corrupt Organizations Act (RICO); Conspiracy to Violate RICO; Intentional Interference with Prospective Economic Advantage, Violation of Unfair Competition Law; and Slander.

The Lupus Foundation of America estimates that 1.5 million Americans, and at least five million people worldwide, have a form of lupus. According to the Lupus Foundation of America most lupus sufferers are misdiagnosed or can go undiagnosed for years. The goal of Lupus Awareness Month is to inform practitioners, patients, care givers, and the general public about how best to diagnose, care for, and live with lupus.

What is Lupus?

Lupus is a chronic (long-term) disease that can cause inflammation and pain in any part of your body. Lupus is a non-contagious autoimmune disease, which means that your immune system — the body system that usually fights infections — attacks healthy tissue instead. According to the Centers for Disease Control and Prevention about 9 out of 10 diagnoses of lupus are in women ages 15 to 44 and most people with lupus develop the disease between the ages of 15-44.

On April 28, 2020, the U.S. Department of Labor’s Employee Benefits Security Administration (EBSA) issued deadline relief and other guidance under Title I of the Employee Retirement Income Security Act of 1974 (ERISA) to help, among other groups, disability plan participants who are impacted by the COVID-19 pandemic, also referred to as the coronavirus outbreak.

The Department of Labor, Department of the Treasury, and the Internal Revenue Service issued a joint notice explaining the extension of time frames for healthcare coverage, portability, and continuation of group health plan coverage under COBRA, and time frames to file a benefit claim or appeal of denied claims.  They also issued COVID-19 FAQs for Participants and Beneficiaries that address a number of common questions concerning health and retirement benefits.

The final rule published by EBSA and submitted to the Office of the Federal Register (OFR) for publication contains information of the extension of certain timeframes under ERISA and the Internal Revenue Code for group health plans, disability and other welfare plans, pension plans, and participants and beneficiaries of these plans during the COVID-19 National Emergency.

If you have a pending ERISA disability claim, the plan administrator or insurance company may schedule an Independent Medical Examination (“IME”) for you.  Your first question may be, “do I have to attend?”  While every person’s situation is different, and you should consult with your attorney about the specifics of your case, it is recommended that you comply with reasonable requests by the administrator to have you evaluated in person.

Why, you ask?  For starters, most disability policies contain a provision that gives the administrator the right to have you examined.  Failure to comply may result in the denial of your claim.  For example, in Burke v. Pitney Bowes Inc., 392 F. App’x 570, 572 (9th Cir. 2010), the Ninth Circuit Court of Appeals held that it was reasonable for the plan administrator to request a second IME of the plaintiff and that the plaintiff’s refusal to attend prejudiced the administrator’s ability to decide the claim.  The Court found that the termination of disability benefits based on the plaintiff’s failure to attend the IME was not an abuse of discretion.

Second, if your matter ends up in litigation, it is important that you appear reasonable and cooperative to the judge.  The focus should be on the merits of your disability claim, not on whether you should have attended an exam.

Kantor & Kantor, LLP, one of the most experienced law firms in the nation dealing with litigating insurance claims against insurance companies, is proud that once again five Partners have been selected to the 2020 Southern California Super Lawyers list.  Co-Founders Lisa Kantor and Glenn Kantor are joined by Senior Partners Alan Kassan and Corinne Chandler, and Partner Brent Dorian Brehm makes his fourth consecutive appearance.

No more than five percent of the lawyers in Southern California are selected by Super Lawyers. Super Lawyers, part of Thomson Reuters, is a rating service of outstanding lawyers from more than 70 practice areas who have attained a high degree of peer recognition and professional achievement. The annual selections are made using a patented multiphase process that includes a statewide survey of lawyers, an independent research evaluation of candidates and peer reviews by practice area. The result is a credible, comprehensive and diverse listing of exceptional attorneys.

The Super Lawyers lists are published nationwide in Super Lawyers Magazines and in leading city and regional magazines and newspapers across the country. Super Lawyers Magazines also feature editorial profiles of attorneys who embody excellence in their practice of law. For more information about Super Lawyers, go to SuperLawyers.com.

A functional capacity evaluation (FCE) is a series of tests that is used to measure a person’s functional physical ability to perform certain work-related tasks. A good, reliable FCE has validity measures embedded within the tests to show that the person taking the tests is putting forth the most effort he can, given his physical limitations. FCEs have many purposes, but in long term disability, we use them to provide objective support of a client’s physical restrictions and limitations with respect to his own occupation or any occupation, if that is the stage of his claim.

Often, in LTD cases, your physician will be asked to complete physical capacity forms. Having an FCE report will assist your doctor in this endeavor by providing her with the exact measurements she needs to provide her opinion.

If you have a condition such as degenerative disc disease, back pain with radiculopathy, fibromyalgia, or many other conditions that result in physical limitations, an FCE can be a very good tool to precisely measure exactly how limited you are by your disabling conditions. We can then use the FCE results to gather further support for your claim by giving it to your physician for her to review and use when she writes a letter of support.

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