Dentist Shoulder Impairments Overcome Insurer’s Improper Application of the Mental Illness Limitation
“Dr. X” was a successful Dentist in Westchester County suffering from major depression, anxiety, and associated symptoms. She applied for benefits and the insurance company granted them under the policy, subject to the two year mental illness limitation in the policy. While out on disability, Dr. X subsequently sustained physical injuries to her right shoulder when she fell walking down a flight of stairs. These injuries, independent of her depression and anxiety, precluded her from performing routine dental procedures with her dominant arm. Dr. X promptly notified the insurance company regarding her physical injuries and submitted medical evidence substantiating her physical restrictions and limitations of her dominant upper extremity. The insurance company, however, discontinued Dr. X’s benefits by invoking the 24-month Mental Illness Limitation, despite the new physical injuries suffered by Dr. X.
Dr. X met with Riemer & Associates and determined that the insurance company improperly applied the 24-month Mental Illness Limitation despite her physical impairments. Riemer & Associates recommended that Dr. X undergo a vocational analysis to clarify her job duties, and a functional capacity evaluation to assess the impact that Dr. X’s physical impairments had on her ability to perform her occupation. The team got to work assisting Dr. X with her appeal, by gathering medical reports and records from Dr. X’s treating providers. The insurance company acknowledged Dr. X had support for partial limitations for her physical impairments, but maintained that she did not satisfy the definition of “Total Disability.” The insurance company offered to pay out partial limitations, which represented a small fraction of the benefits Dr. X was entitled to.
Mr. Riemer agreed to file a lawsuit in federal court on behalf of Dr. X recognizing that the insurance company’s offer to pay out partial limitations was financially too low in light of the insurer’s own admission that Dr. X suffered from a physical impairment of her neck and dominant upper extremity. Mr. Riemer was able to settle the case with the insurer for a sum that was satisfactory to Dr. X shortly after the lawsuit was initiated saving both parties substantial legal costs and time.
Millions Gained in an ERISA Class Action
“George” had been a loyal employee of a major bank for over ten years, when the division he worked for was sold off to a competing company and his employee stock ownership plan (ESOP) was partially terminated due to the sale. Strongly believing that he was being unfairly deprived a fair share of the earnings on his investment in the ESOP, he sought expert legal advice.
George came to Riemer & Associates for help. The Firm reviewed George’s documents and quickly came to the conclusion that the bank could be sued under ERISA to recover a proportionate share of the accumulated earnings in the plan. Because 1,100 other employees were similarly affected by the partial termination of the ESOP, the Firm commenced a class action against the bank.
George took an active role in the case and was essential in recruiting the 24 other named plaintiffs. The case settled for millions of dollars just before trial. The Firm celebrated the settlement by holding a party aboard the World Yacht inviting all of the name plaintiffs and their spouses.
Precedent Established for Interest on Delayed Benefits
“Alice” was an accountant at a major accounting firm. As a result of the debilitating symptoms of Chronic Fatigue Syndrome, she was forced to apply for disability benefits. For almost five years, the insurance company continued to turn down Alice’s appeals, which she handled herself.
Discouraged and frustrated, Alice came to Riemer & Associates. We decided to file one more appeal on Alice’s behalf. Finally, the insurance company agreed to pay her benefits-but it was five years too late because Alice already had lost her home and savings. Given the length of time it took the insurance company to pay Alice’s benefit, the Firm demanded that it at least pay interest on the delayed benefits. The insurance company refused.
The Firm commenced a class action in Federal Court, asserting that the insurance company owed interest to all claimants who were paid benefits in an untimely manner. Although the Court ultimately ruled that the case could only proceed on an individual basis and not as a class action, the lawsuit established an important legal precedent. An insurer that pays interest in an untimely manner is now liable for interest if it caused the delay. Alice was thrilled with the outcome. In a short note, she wrote
Thank you for representing me. Thank you for standing for the people who are too sick to make a claim stand. When I think of David & Goliath, I think of you as the same. Many blessings to you and your lovely family.
Depression Incapacitates a Senior Manager
“Larry” was a senior manager at a major consulting firm. As a result of a series of major stresses in both his personal and professional life, Larry was hospitalized with major depression and suicidal ideation. When the insurance company denied Larry’s claim, Larry hired Riemer & Associates to prepare an appeal. The Firm submitted comprehensive letters from Larry’s treating psychiatrists, who opined that Larry was disabled from any occupation; detailed statements of Larry’s family and co-workers, corroborating his incapacity; and an in depth affidavit from Larry describing how depression slowly but surely made him unable to function and took away all joy in his life. The insurance company still denied Larry’s appeal, asserting that Larry did not submit objective proof of his depression even though it is well known that disability from depression cannot be demonstrated “objectively.”
Riemer & Associates immediately commenced a lawsuit on Larry’s behalf in Federal Court. Our persistence eventually convinced the insurer to settle the case. Larry received a substantial lump sum settlement and can now get on with his life.
Hearing Loss Impairs a Wall Street Trader
“Arnold” was a successful trader at a small brokerage firm reaping the benefits of a strong market. Unfortunately, Arnold was struck in the head during a mugging, and as a result suffered permanent left-sided hearing loss, including conductive as well as high frequency sensorineural hearing losses. Even though Arnold can hold a conversation with someone in a quiet room, he has tremendous difficulty hearing in a noisy environment such as a trading room. The insurance company denied Arnold’s claim for long term disability benefits on the unscientific premise that his hearing deficit could be corrected by a hearing aid.
Riemer & Associates commenced a lawsuit on his behalf in Federal court. The Firm prepared a detailed motion for summary judgment arguing that there was substantial scientific evidence establishing that a hearing aid would make Arnold’s hearing loss worse not better. Rather than opposing the Firm’s motion, the insurer approached the Firm for a settlement. A settlement was reached providing Arnold with a substantial lump sum payment.
Spondylolisthesis ravages a young Attorney
“Barbara” was an ambitious young associate attorney at a major law firm. She had been hampered by a degenerative back and spine condition most of her life but was still driven to complete law school and obtain a job at a prestigious law firm. By the time that she reached her early 30’s, however, Barbara could no longer fight her debilitating pain. She stopped work and applied for disability benefits on her own.
The insurance company turned down Barbara’s claim as well as her subsequent appeals, asserting that Barbara submitted insufficient proof of disability for her “sedentary” occupation.
Barbara came to Riemer & Associates, knowing that she needed expert advice.
Prior to commencing litigation, the Firm submitted an additional appeal in an effort to bolster the claim file. The appeal contained substantial new evidence from Barbara’s treating physicians and a detailed affidavit from Barbara explaining the activity level required of her job. When, as expected, the insurer turned down the additional appeal, the Firm commenced a lawsuit on Barbara’s behalf in Federal court. With the potential impact of the newly submitted evidence, a settlement was reached providing Barbara with a substantial lump sum. Barbara can now get on with her life without the constant fear of financial ruin.
Fibromyalgia Devastates An Engineer
“Carol” was a feisty engineer at a major communications company working in the field with a group of men. She was required to conduct on-site inspections, sometimes requiring her to crawl through cable tunnels. It was a very demanding job, but she loved it. When Carol became afflicted with Fibromyalgia she attempted a part-time schedule but was ultimately unable to work even in a limited capacity.
Upon submitting her claim for LTD benefits, the Company’s plan denied Carol’s benefits on the ground that she did not submit objective proof of disability from her “sedentary” occupation.
Carol was referred to Riemer & Associates by her Social Security representative.
The Firm commenced a lawsuit in Federal court on Carol’s behalf. A settlement agreement was ultimately negotiated by the Firm, which included a lump sum for past benefits, interest and attorney fees.
Under the settlement agreement, Carol was permitted to submit proof of continued disability in the future. Initially, the administrator for the LTD plan denied Carol’s claim for continued benefits. Once again, however, Riemer & Associates persisted and ultimately the plan placed Carol on long term disability and has paid her benefits without interruption.
Chronic Fatigue Syndrome Attacks a Data Manager
“Christine” was employed as a data manager at a newspaper when she became terribly ill with Chronic Fatigue Syndrome. For more than a year Christine struggled to continue to work, only to find that each day it became more and more difficult.
She applied for long term disability benefits to the insurance company that the newspaper had hired to administer its Plan. She was denied benefits and appealed the denial through several levels of appeal at both the insurer and at the Plan. She was never told a specific reason for her denial, only that what she submitted was not enough.
Christine contacted Riemer & Associates for help. As part of our litigation strategy, we decided to file another appeal which contained additional tests and reports. In litigating this type of claim, it is imperative that the ‘administrative record’ of medical reports which had been submitted to the insurance company is complete because a court will often limit its review to what the insurance company had considered. The Court determined that the insurer and plan failed to provide Christine with a “full and fair review” by failing to tell her what documentation was specifically missing from her claim. When the plan was forced to tell Christine what was missing from her application, Christine provided it and benefits were granted. The Court also ordered the Plan to pay Christine for all attorney’s fees and costs she incurred.
Contact Our New York Disability Lawyers
Our knowledgeable New York disability lawyers will dedicate the time and energy you deserve. Call Riemer & Associates, LLC, Attorneys at Law, today at 212 297 0700.