Articles Tagged with Kantor & Kantor

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.

Most ERISA-governed long term disability policies include a limitation on the amount of time they will pay benefits when the disabling condition is one that the policy defines as a “mental/nervous” condition.  Policies vary as to what they include in their definition of “mental/nervous” conditions and the wording of the limitation varies, too.  A note about the wording of the limitation – it is extremely important how the policy words the limitation in terms of how evidence of a condition such as depression or anxiety is presented in a claim.

Generally, the limitation is 24 months of benefits will be paid if the claimant is disabled by a mental/nervous condition such as depression or anxiety. There are conditions, such as Multiple Sclerosis, Parkinson’s Disease, migraines, and disability after heart attack to name a few, that either have depression as a symptom of the disease itself, and/or result in depression from dealing with the disease.  In such cases, you may not be disabled at all by depression but if it is mentioned in your medical records – and it very likely will be – very often an insurance company will seize upon the depression and attempt to apply the policy’s 24-month benefit limitation to your claim.

If your only disabling condition is a mental/nervous condition, and your policy contains a 24-month limitation, it may also contain a 12-month extension of benefits should you be hospitalized for your mental health condition at the end of the 24-month period.  These are highly technical exceptions that often require the assistance of attorneys who understand how these exceptions are applied.

Breast-Cancer-Awareness
According to the Centers for Disease Control and Prevention (“CDC”), breast cancer is the second most common cancer among women in the United States.

  • In 2019, an estimated 268,600 new cases of invasive breast cancer will be diagnosed in women in the U.S. as well as 62,930 new cases of non-invasive (in situ) breast cancer.
  • Men also get breast cancer, but it is not very common. Less than 1% of breast cancers occur in men.

An Independent Medical Examination (IME) is an examination by a medical doctor hired to examine you and opine on your disease state and whether it is disabling. If so, the IME can help determine the degree to which is it disabling and its impact on your ability to perform the duties of your own or any occupation, depending upon the stage of your LTD claim.

IMEs are typically quite expensive so we are judicious in when we recommend them to our clients. We recommend them in a variety of situations and this blog does not cover every situation. Of course, we make these determinations on a case-by-case basis for each of our clients but we can offer some general information here.

If your attending physician does not wish to participate in the appeal process by writing letters, responding to medical record reviews from the insurer, or completing questionnaires necessary to a successful appeal, then an IME may be appropriate for your case.  Another situation in which we might recommend an IME is if you suffer from a particular medical condition and there is an IME provider who is a well-known expert in the diagnosis and treatment of that condition.

Kantor & Kantor Partner Elizabeth Hopkins filed an Amicus Brief in the Supreme Court on September 18, 2019 for The Pension Rights Center in support of the petitioners in Thole v. U.S. Bank, N.A.  The case is about funding in defined benefit pension plans, constitutional standing, and when participants in these plans may sue to recover plan losses.

Please see the brief here: Thole v. U.S. Bank, N.A. Amicus Brief

For questions on the handling of your Pension benefits, please do not hesitate to contact Kantor & Kantor for a no-cost consultation at (800) 446-7529 or use our online contact form.

 

The Women’s Health and Cancer Rights Act of 1998 (WHCRA) was signed into law on October 21, 1998.   The WHCRA provides protections for individuals who elect breast reconstruction after a mastectomy. The WHCRA covers women who undergo a mastectomy for any medical reason, not just to treat breast cancer.

Under WHCRA, if your group health plan covers mastectomies, the plan must provide coverage for certain services relating to the mastectomy. However, if your coverage is provided by a “church plan” or “governmental plan”, you will need to check with your plan administrator as certain plans may not be subject to this law.

WHRCA rights apply to individual coverage as well and are generally within the jurisdiction of the state insurance department where you live.

Attend our October 2 Webinar About Insurance Coverage

You have had or are considering explant surgery.  We understand the physical and emotional pains that made you decide on the procedure.  We also understand that thinking about insurance coverage should be the farthest thing from your mind.

We have spoken with so many women about their troubles getting insurance coverage for these explants, that we thought it may help to put together some ideas, facts and resources that may resolve at least one part of these ordeals.

National Suicide Prevention Week (“NSPW”) is September 8th-14th this year. Each year, the nation’s largest suicide prevention organization, the American Foundation for Suicide Prevention (“AFSP”), hosts NSPW. One focus of NSPW this year is: Creating A Safety Net.This blog is a little bit about how I created a Safety Net for myself, and why you need one, too.

Why Do You and I Need A Safety Net?

Each of us lives a life in which our experience of living may bring along some challenges. I venture that most would agree that life is not a linear or static journey -neither in a practical or emotional sense. Personally, I have found that this great sweep of things we call “Life,” although a wonderful journey, it has not been one of predictability. While I have enjoyed years of stability and joy, years of happiness, years of feeling inspired, I have also faced years of hard-times, loss, defeat and great suffering.

The correct response is, “maybe, or maybe not, depending on the facts, and the state in which you reside.”

Insurance policies very often have time limits on the submission of a claim for benefits. In some states, those deadlines are VERY strictly construed, and once the deadline has passed, it does become “too late” to make a claim.

However, more than half of the states apply some form of an insurance rule called the “notice prejudice” doctrine.  Simply put, even if an insurance policy imposes a time limit for the submission of the claim, if certain rules are met, a claim can be submitted after the time limit if the late notice does not “prejudice” the insurance company’s ability to investigate the claim.  However, that is just a basic summary of the rule.  In the states that apply some form of the notice prejudice doctrine, its application differs from state to state.  In some states, the insured making the late claim must demonstrate a “good reason” for making a late claim.  In others, the burden falls on the insured to prove that no prejudice would be suffered by the insurance company because of the late claim submission.

On August 16, 2019 a nationwide class action lawsuit was filed in the U.S. District Court for the District of New Jersey against the medical device manufacturer Allergan to protect women with Allergan’s textured breast implants from the increased risk of breast implant-associated anaplastic large cell lymphoma (BIA-ALCL), which has now been associated with Allergan’s BIOCELL textured breast implants. The case is Jane Doe I, et al. v. Allergan, Inc., et al., No. 2:19-cv-16784 (D.N.J.).

In July, The United States Food and Drug Administration (FDA) requested that Allergan issue a recall of its BIOCELL textured breast implants and tissue expanders, and Allergan agreed and is removing these products from the global market.

The FDA requested that Allergan recall all of its BIOCELL textured breast implants and tissue expanders based on newly submitted Medical Device Reports (MDRs) reporting worldwide cases of BIA-ALCL and BIA-ALCL-related deaths associated with these implants. The FDA’s “analysis was attributed to a new worldwide reported total of 573 unique BIA-ALCL cases including 33 patient deaths. Of the 573 cases of BIA-ALCL, 481 are reported to have Allergan breast implants at the time of diagnosis. In addition, 12 of 13 deaths occurring in patients with BIA-ALCL where the manufacturer was known occurred in patients implanted with an Allergan breast implant at the time of their BIA-ALCL diagnosis. The manufacturer and/or texture is unknown for the remaining 20 reported deaths from BIA-ALCL.”

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