Articles Tagged with Kantor & Kantor

Glioblastoma, also known as glioblastoma multiforme, is an aggressive type of cancer that can occur in the brain or spinal cord. Glioblastoma can occur at any age but tends to occur more often in older adults. Many glioblastoma symptoms develop slowly and get worse over time. Common symptoms may include:

  • Headaches
  • Loss of appetite

Here at Kantor & Kantor, we like to refresh and give updates to certain parts of the process we use to help individuals. We feel that the more people understand their insurance benefits, the better they will be able to fight when benefits are denied. Long-term disability (LTD) insurance is a large part of this process, so we will explain the basics here.

Long-term disability insurance is an insurance policy that protects an employee from loss of income in the event that he or she is unable to work due to illness, injury, or accident for a long period of time.

LTD can provide benefits for work-related accidents or injuries that are covered by Workers’ Compensation insurance, but there usually will be an offset, where the LTD benefit is reduced dollar-for-dollar by the amount of Workers’ Compensation payment. LTD also does cover an employee in the event of a personal accident such as a car accident or a fall.

When the disability insurance attorneys at Kantor & Kantor, LLP see what is happening with those whose COVID-19 symptoms are continuing for more than a month, they know that there is a good chance that long-term disability claims will be denied. Because of this, we have developed the COVID Longhaulers Legal Resource Center.

In fact, the symptoms that Longhaulers are experiencing match many of the same disabling symptoms those living with autoimmune diseases such as ME/CFS, Dysautonomia, POTS, and more.

Since the symptoms dovetail, we are confident that the inevitable problems and denials with the long-term disability insurance providers will follow suit.

Aaron Monheim, age 34, lives in Spokane, Washington with his wife and three year old daughter. In 2019, Aaron was diagnosed with aggressive relapsing remitting multiple sclerosis which has been unresponsive to medications and leaves Aaron partially disabled due to frequent flares and relapses.

Aaron’s physicians recommended him to receive a treatment called hematopoietic stem cell transplantation, found to be particularly suited for his form of relapsing remitting multiple sclerosis. The treatment will effectively reset his immune system so it will no longer attack his central nervous system. The treatment is also less costly than the traditional medications for multiple sclerosis which have been unsuccessful for Aaron.

Despite having been referred to the treatment by his own Kaiser doctor, Aaron’s health plan, Kaiser Permanente, has denied benefits for the treatment claiming the treatment is not necessary or suited for Aaron’s condition.

Multiple sclerosis (MS) is a potentially disabling disease of the brain and spinal cord (central nervous system). In MS, the immune system attacks the protective sheath (myelin) that covers nerve fibers and causes communication problems between your brain and the rest of your body. Eventually, the disease can cause permanent damage or deterioration of the nerves.

Signs and symptoms of MS vary widely and depend on the amount of nerve damage and which nerves are affected. Some people with severe MS may lose the ability to walk independently or at all, while others may experience long periods of remission without any new symptoms. While there is no cure for MS, treatments can help speed recovery from attacks, modify the course of the disease, and manage symptoms.

The National MS Society estimates that more than 2.3 million people have a diagnosis of MS worldwide and approximately 1 million people over the age of 18 in the United States have a diagnosis of MS.

May 2021: May is Mental Health Awareness Month. In honor of that, the American Foundation for Suicide Prevention (“AFSP”) is encouraging #MentalHealth4All. The hashtag is behind AFSP’s campaign that seeks to spread this important message:

No One’s Mental Health Is Fully Supported Until

Everyone’s Mental Health Is Fully Supported.

Autoimmune disease is a broad category of related diseases in which a person’s immune system mistakenly attacks the tissues and organs it was designed to protect. Normally, the body’s immune system protects it by responding to invading microorganisms, such as bacteria and viruses. The immune system produces antibodies, which are special proteins that recognize and destroy the invaders. Autoimmune diseases occur when these autoantibodies attack the body’s own cells, tissues, and organs.

Autoimmune Facts:

  • There are more than 100 autoimmune diseases.

Weissman v. United Healthcare Ins. Co., et al., 19-cv-10580, (D. Mass. Mar. 8, 2021) (Judge Allison D. Burroughs). A putative class of former patients, who were denied life-saving, quality-of-life maintaining proton therapy cancer treatment, brought a putative class action alleging that UnitedHealthcare and the lead putative class plaintiffs’ employer-based health plans breached their fiduciary duties by wrongfully denying medically necessary proton therapy cancer treatment. Lead class plaintiff, Kate Weissman, and her family were able to come up with over $125,000 to privately pay for medically necessary proton therapy treatment to treat her cervical cancer diagnosis after UHC denied her treatment in 2016. Kate, along with other proton therapy patients—Zachary Rizzuto and Richard Cole—brought this putative class to vindicate their rights under ERISA and for potentially countless others challenging UnitedHealthcare’s application of narrowly-restrictive, flawed, out-of-date internal coverage guidelines to wrongfully deny claims for proton therapy.

On March 8, 2021, the Court denied in full UnitedHealthcare’s motion to dismiss the putative class’ (1) claims for denial of benefits and (2) claims for breaches of fiduciary duty.  The Court concluded that Plaintiffs had plausibly alleged that Defendants acted arbitrarily and capriciously in denying their claims for proton therapy. Order, p. 17. Above and beyond this determination by the Court, Judge Burroughs also made clear that “[n]otwithstanding Defendants’ arguments to the contrary, Plaintiffs have alleged more than just that their requests for pre-authorization for PBRT were arbitrarily and capriciously denied. Rather, they have alleged that UnitedHealthcare has developed and applied the PBRT Policy [UnitedHealthcare’s separate coverage policy] to broadly deny coverage for PBRT, even though it is safe and effective, because it is more expensive than IMRT. . . If these allegations are borne out, § 1132(a)(1)(B)’s remedy of repayment of benefits may turn out to be inadequate, and it would therefore be premature to foreclose the possibility of equitable relief, including an accounting and disgorgement [of UnitedHealthcare’s profits from wrongfully denying PBRT claims].” Order, p. 19 (citations omitted).

Finally, the Court also concluded that “even if Plaintiffs can ultimately prove only that UnitedHealthcare breached its fiduciary duty by impermissibly denying their benefits, it is possible that relief under § 1132(a)(1)(B) would still be insufficient. In other words, it is conceivable that even past due benefits, prejudgment interest, and attorneys’ fees may not put Plaintiffs in the position they would have been in but for UnitedHealthcare’s alleged misconduct.” Order, p. 20.

One of the most crucial pieces of evidence in supporting a long term disability (LTD) claim is the opinion of the claimant’s treating physician that he or she is disabled.

Many physicians are more than happy to assist their patients with forms required by the LTD provider and in some cases, narrative accounts of their patient’s disabling condition. Sometimes, though, the doctor is unable or unwilling to assist. There are a variety of reasons for this: lack of time, lack of compensation, misunderstanding of the level of involvement required by the doctor, employer/hospital rules preventing them, and in some cases, a disbelief that their patient is actually disabled.

If you have a disabling condition and you are making an LTD claim, or you are receiving benefits, your doctor’s participation in the process is essential. Without a doctor’s support, in most cases, your claim is finished. If your doctor has notified you that he or she will not be able to assist you with your claim, it is important to ask him or her to tell you the reason for their decision. If it is anything other than lack of belief that you are disabled, often, further information can change their minds. The offer of additional compensation for their time is a big help. Explaining that they will not have to do anything more than the forms or a letter – that they will not have to testify in court – goes a long way in changing minds.

An alternative to health insurance marketplaces available through healthcare.gov are “short term” health insurance plans purchased through insurance brokers.

These short term plans have surprisingly low premiums and even slimmer coverage. The problems with these short term plans have caused four states – California, Massachusetts, New Jersey, and New York – to ban them.

Insurance brokers are incentivized with higher commissions to sell short term plans compared to Affordable Care Act (“ACA”) plans.  See more from Consumer Reports HERE

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