Denials of Long Term Disability Claims because of No Improvement in Your Medical Condition

Unfortunately it is not uncommon for Long Term Disability carriers to play games in Long Term Disability claims particularly when the policy definitions changes from own occupation to any occupation.

Many times the Long Term Disability carrier will find that you are totally disabled from performing your occupation and pay Long Term Disability benefits but notify you that they will re-review your claim when your policy definition changes to “any occupation.” For example in Saffron vs. Wells Fargo & Company LTD Plan, 522f.3d863 (9th Circuit 2008), Mr. Saffron had an MRI in April of 2003 that should degenerative changes and remained unchanged from an earlier MRI of January 12, 2002. MetLife had accepted Ms. Saffron’s Long Term Disability claim and had them paying for Long Term Disability benefits. They denied the claim, because they said there was no improvement. How weird is that? MetLife didn’t explain why further degeneration was necessary to sustain the continued finding that Ms. Saffron was disabled. In order to find her “no longer disabled” one would expect the MRIs to show an improvement, not a “lack of degeneration.” Needless to say the court was not impressed with MetLife in the Saffron case and awarded benefits.

Getting benefits doesn’t operate as an unstoppable. Insurance companies can suspend the payment of Long Term Disability benefits when information available to them alters “in some significant way” the basis for the payment of benefits. In the 11th Circuit, the court held in Levinson v. Reliance Standard Life Insurance Company, 245f.3d.1321 (11th Circuit 2001), that where a carrier accepts a claim and then later cuts off benefits, the burden switches to the carrier to prove that the claimant is no longer disabled.

There is no presumption of continuing disability, but there is certainly an obligation for the Long Term Disability carrier to have meaningful evidence in the record showing that there has been a change in the condition that establishes that the claimant is no longer disabled.

If the Long Term Disability carrier is using the excuse that there has been “a failure to show improvement,” to terminate your Long Term Disability benefits, call or contact Dearborn National disability claim attorney Nancy Cavey.