Articles Tagged with Kantor & Kantor

We represent many clients who have been denied long-term disability benefits in lawsuits against the insurance companies who have denied their claims. Many of our clients ask, “What is the value of my disability claim?”

This question usually presents itself in the context of mediation, which is a form of voluntary alternative dispute resolution, because our clients must decide whether to take the insurance company’s lump sum settlement offer. There are many factors to consider. To aid our clients’ decision-making process, we will prepare a “present value calculation” designed to capture the total value of all benefits in dispute.  In most circumstances, the value of your benefit can be broken up into two parts:  the past-due benefits and the future benefits.  Benefits, both past and future, are calculated by taking your net monthly benefit (total gross monthly benefit minus offsets” for other income you receive) and multiplying by the number of months benefits are due. However, past and future benefits have to be calculated differently in order to account for inflation.

Past-due benefits are calculated by multiplying the net monthly benefit by the number of months of past-due benefits you are owed. Then, we add interest to compensate you for the fact that, had you been properly paid your past-due benefits, those benefits would have been worth more in the past than they are in the present, because inflation has made the value of each dollar decrease over time.  Notably, the insurance carriers seldom factor in interest on the past-due benefits in the context of mediation. However, if your case does not settle and the court makes a decision in your favor, it has the discretion to award prejudgment interest on the past-due benefit. The percentages that courts award vary and range from the nominal interest amount rate dictated by 28 U.S.C. § 1961 (1-year constant maturity Treasury yield) to 10% interest. See, e.g., Blankenship v. Liberty Life Assur. Co. of Bos., 486 F.3d 620, 628 (9th Cir. 2007) (affirming award of prejudgment interest at a rate of 10.01 percent, compounded monthly); Oster v. Standard Ins. Co., 768 F. Supp. 2d 1026 (N.D. Cal. 2011) (finding current U.S. Treasury Rate at .3% too low and awarding prejudgment interest at the rate of 5% ).

In addition to dealing with short term disability benefits, long term disability benefits, and health insurance denials, many of our clients are also tasked with keeping track of changes to their Social Security benefits. Here are some of the changes that will take effect on January 1, 2020 for Social Security recipients –

  • Social Security recipients will get a 1.6 percent cost-of-living adjustment (COLA) in their monthly benefits starting in January. The average individual retired Social Security beneficiary is expected to see a monthly benefit jump from $1,479 to $1,503, an increase of roughly $24 per month or $288 for the year.
  • As a result of the COLA, the maximum monthly benefit a single recipient can get also will grow. That benefit will increase from $2,861 per month in 2019 to $3,011 per month in 2020.

Kantor & Kantor Partner Elizabeth Hopkins filed an Amicus Brief in the Supreme Court on October 28, 2019 for The Pension Rights Center in support of the Ninth Circuit in Intel Corp. Investment Policy Committee et al. v. Christopher M. Sulyma  The case is about whether workers get six years or three years to sue over ERISA violations.

Please see the brief here:  18-1116bsacPensionRightsCenter

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.

In his October 28, 2109 Opinion piece published by The Philadelphia Inquirer, Ross Waetzman opened with this harrowing sentence, “I almost died because of insurance prior authorization rules.” His story went on to share the details of how he nearly died as a result of the decision made by his insurer, Independence Blue Cross (“IBC” or “IBX”), to deny authorization of benefits for a test that had been recommended by Mr. Waetzman’s cardiologist.

The test Mr. Waetzman’s cardiologist had recommended was a cardiac catheterization. The test was necessary because Mr. Waetzman’s history of chest pain had been increasing in intensity, despite lifestyle changes he had made in an attempt to curb his symptoms. The cardiac catheterization was recommended by Mr. Waetzman’s cardiologist after less-invasive tests had been performed. Those less invasive tests, an EKG and a coronary calcium test, revealed that Mr. Waetzman was in the top 10% for his age and race for calcium deposits on his coronary arteries. With such deposits known to result in reduced blood flow to the heart, the cardiac catheterization was recommended to determine if Mr. Waetzman’s chest pain was a result of a blocked artery.

Unfortunately, when Mr. Waetzman’s cardiologist, Dr. Kenneth Mendel, called IBX, he was informed that “prior-authorization” for the cardiac catheterization was denied. IBX claimed that Mr. Waetzman did not meet all the necessary criteria to have the test and his only available option was to appeal the denial.

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.

Contact Information