Articles Tagged with insurance denials

Kantor & Kantor won a notable victory against the Life Insurance Company of North America (also known as “LINA” or “Cigna”) in Elliott v. Life Insurance Company of North America, Inc., No. 16-CV-01348-MMC, 2019 WL 2970843 (N.D. Cal. July 9, 2019), a case in the San Francisco Bay Area involving a denial of long-term disability benefits to the plaintiff who is disabled by trigeminal neuralgia.

The plaintiff, Elliott had to stop working in his position as Vice President of a brokerage firm due to symptoms from trigeminal neuralgia, a chronic pain condition affecting the trigeminal nerve, which is a cranial nerve responsible for sensation and certain motor functions in the face. Elliott was experiencing symptoms including shooting facial and head pain on a daily basis, migraines, difficulty talking, as well as medication side effects including sedation and cognitive slowing.

LINA had approved Elliott’s initial claim for short-term-disability, but denied his claim for long-term disability benefits and upheld its denial on appeal, stating that there was a lack of objective evidence to support his diagnosis. After the Social Security Administration approved Elliott’s social security benefits claim, finding him disabled, LINA had another opportunity to reconsider its decision deny Elliott’s claim but declined to do so.

There is almost nothing more important to a successful disability claim than a supportive physician. At every point of your claim, you will need the help of your doctor. At the initial claim, your doctor will be asked to complete a form certifying that you are disabled and providing detailed information about the symptoms you have that prevent you from performing the duties of your occupation. She will also be asked to provide your restrictions and limitations that prevent you from working.

If you have been awarded disability benefits and you are “on claim,” your insurance company will ask your doctor for information on your condition as it periodically investigates whether you remain disabled under the terms of your policy.

You will need a doctor who is willing to fill out forms sent by the insurance company. More importantly, you will need a doctor who understands that if she is too quick with these forms and does not pay attention, noting that you “can sit frequently” when she means you are fine to sit at home on your sofa and does not intend to say you are fine to go back to work can be enough to get your claim denied.

Due to their depth and breadth of knowledge, the attorneys at Kantor & Kantor are frequently asked to speak at seminars, conferences, or give presentations. In June of 2019, partner Brent Dorian Brehm was asked by a national continuing legal education (CLE) provider to speak about long term disability benefits.  The seminar was titled “Mastering Social Security, Long-term Disability & Government Benefits.” Mr. Brehm took the attendees on a journey from the start to the end of a long term disability claim – and everything in between. He also covered relevant differences between disability claims governed by state law and those governed by ERISA.

While we cannot provide you with the actual presentation or the question and answer segment that followed, we can provide Mr. Brehm’s outline. This information is valuable to anyone at any stage in the long term disability claim process. It starts from the beginning – explaining what LTD benefits are. It then goes through tips on making a successful LTD claim. It addresses what needs to be done during the claim stage to avoid litigation – but be ready for it if that must happen. And finally reviews the nuts and bolts of litigating both an ERISA and bad faith disability claim.

What are long term disability benefits?

Kantor & Kantor, LLP is pleased to announce that for the fifth consecutive year (after three years as a Rising Star), Michelle L. Roberts has been selected to the 2019 Northern California Super Lawyers list.  No more than five percent of the lawyers in the state are selected by the research team at Super Lawyers to receive this honor. To top that off, Ms. Roberts was once again named as one of the Top 50 Women and Top 100 Attorneys.

And in the first of what we are confident will be many accolades, Andrew M. Kantor has been selected to the 2019 Southern California Rising Stars list in the Employee Benefits practice area. Each year, no more than 2.5 percent of the lawyers in the state are selected by the research team at Super Lawyers to receive this honor.

Super Lawyers, a Thomson Reuters business, 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 the practice of law. For more information about Super Lawyers, visit SuperLawyers.com.

It’s a common story shared by an increasing number of women. They received breast implants and after a period of time they started getting sick.  While we do not know the exact number, we know that the largest Facebook Group has grown to nearly 83,400 members, with an increase of more than 5,200 in the last 30 days.

A client, whose name is being kept anonymous to protect her privacy, contacted Kantor & Kantor recently for help with an insurance denial. The woman was in failing health and had been experiencing severe medical complications dating back to 2012 after receiving breast implants. The woman referred to her condition as “breast implant illness.”

After consulting with her primary care physician, the woman underwent a bilateral breast MRI which revealed findings consistent with intracapsular rupture in the left breast. Shortly after, she was referred to a plastic surgeon who recommended bilateral breast capsulectomy and implant removal. The procedure, referred to as explant surgery, involves the removal of the implants and the surrounding capsules (or scar tissue).

Researchers at Stanford University recently made exciting and significant progress toward developing a possible diagnostic test for chronic fatigue syndrome, or ME/CFS. In a pilot study of 40 people, half healthy and half with ME/CFS, all of the patients with ME/CFS showed a potential biomarker, where the healthy individuals did not.  More details can be seen HERE

As sufferers of ME/CFS know, the struggle to obtain not only treatment, but mere confirmation of the existence of a real disease, can be overwhelming. While the new test itself is still viewed with significant skepticism due to the study’s small sample size, it could be the first step in finding a reliable, objective test to confirm the presence of this debilitating disease.

Disability insurance companies deny claims based on ME/CFS at an extraordinary rate; not because these claims are not righteous. Rather, without a medically accepted diagnostic test, insurers can dismiss your devastating limitations as mere “subjective reports.” Fortunately for consumers, insurers’ attempts to dismiss such claims can be fought, and won, with the right expertise.

Kate Weissman is willing to brave litigation with a $150 billion health insurance company to bring about change in our healthcare system. On March 26, 2019, Ms. Weissman filed a class action lawsuit to challenge what she alleges to be UnitedHealthcare’s unfair and deceptive policies and procedures for determining whether a prescribed treatment or medication is medically necessary (utilization review). Ms. Weissman alleges that UnitedHealthcare’s utilization review process is skewed toward the denial of coverage based upon inadequate internal medical policies placed in the hands of unqualified medical directors.  This alleged institutional pattern and practice of wrongful conduct results in the systematic denial of coverage for medically necessary proton beam radiation therapy (“PBT “) for UnitedHealthcare’s insured members suffering with cancer, while offering coverage for far less expensive, though far more harmful, conventional radiation treatment.

In October 2015, 30-year-old Ms. Weissman was diagnosed with stage IIB cervical cancer. After various treatments and a relentless battle for her life, her doctors from Massachusetts General Hospital recommended PBT to avoid grave damage to surrounding tissue and organs. On April 6, 2016, UnitedHealthcare denied coverage, contending that PBT is experimental or investigational or unproven. Ms. Weissman alleges that PBT is an established form of treatment that is widely accepted by physicians, government agencies and many insurers and other payers, including Medicare and Medicaid. UnitedHealthcare relied on its own internal policies, as interpreted and applied to Ms. Weissman’s case by UnitedHealthcare’s medical directors, in denying coverage for PBT.  UnitedHealthcare would only agree to cover the more conventional intensity-modulated radiation therapy, which is about half the cost of PBT.

Ms. Weissman, who volunteers with Cervivor to advocate for the cervical cancer community, recognizes that she was fortunate enough to have the $95,000.00 to pay for the proton beam treatment ordered by her doctors so that she would not have to settle for the more dangerous and damaging conventional treatment. She is now fighting for those who cannot afford that choice.

A recent analysis of 2016 National Survey of Children’s Health data indicated that as many as one in six U.S. children between the ages of 6 and 17 has a treatable mental health disorder such as depression, anxiety problems or attention deficit/hyperactivity disorder (ADHD). The analysis published in JAMA Pediatrics also found that nearly half of children with these disorders did not receive counseling or treatment from a mental health professional such as a psychiatrist, psychologist or clinical social worker.

Early diagnosis and treatment are very helpful for these children, but some families may have trouble accessing mental health care.

Problems accessing mental health care come in various forms. Some families may struggle to get the care their children need due to a shortage of child psychiatrists, psychologists, and behavior therapists. Other families may not have a mental health provider in the vicinity and may not be able to travel long distances to visit one. And for some families, their insurance company may not authorize the treatment and the family simply cannot afford to pay out-of-pocket for the care their child needs.

In a previous blog, we discussed the steps you need to take if you have a long term disability claim through a policy provided by your employer, before you hire an attorney. This blog will piggyback on that one, focusing on why the appeal itself is so important and more importantly why the quality of the evidence you submit during that appeal will make or break your claim.

Under the federal regulations that govern ERISA claims and the cases that have interpreted those regulations, your appeal is the only opportunity you will have to get evidence of your disability into your claim file. (There are a few exceptions to this general rule but for purposes of most cases, the appeal is it).

While you do have a right to litigate your claim once you have exhausted your administrative remedies under the plan, you do not have the right to testify, call witnesses or present new evidence to the judge. All the judge will see, if your claim goes that far, is the evidence that was submitted during your administrative appeal.  Thus, the type and quality of the evidence you submit during your appeal is crucial to a successful claim.

During an office visit with your doctor, she recommends you undergo a treatment you’ve never had before. You call your health insurance company, and a representative assures you the treatment is covered by your health insurance plan. Can you rely on what the representative says? Will the treatment be covered by your insurance?

Caution is Key

Be cautious when relying on what health insurance representatives tell you over the phone. The representative can give you general information about what services are covered by your health insurance, but she cannot guarantee that you have met all the requirements under the terms of your policy for the treatment to be covered for you.

Contact Information