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  • Long Term Disability Guide

    Robbed of Your Peace of Mind? Your Guide to Long Term Disability Benefits

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    The Key To Hiring The Right Long Term Disability Attorney

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    The Smart Long Term Disability Guide For Preparing Your Statement and Field Visit

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  • Social Security Disability Guide

    Your Rights To Social Security Disability Benefits - Your Guide to Getting Benefits Now

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Category Archives: Long Term Disability ERISA and Private Disability Insurance Claims

Cognitive Dysfunction And Your Claim For Long Term Disability Benefits

Cognitive Dysfunction

Long term disability carriers don’t make it easy for those who are disabled to get the long term disability benefits that they deserve. Long term disability carriers deny claims on the basis of:

A. Lack of diagnostic criteria;

B. No clinical connection with disabling medical condition; and

C. No objective medical or self-reported symptoms and limitations.

Cognitive Dysfunction

Cognitive Dysfunction

Cognitive dysfunction is present in a number of medical conditions, including tinnitis, hearing loss, headaches and vertigo.

Cognitive dysfunction isn’t evidence of a disability but it’s an important factor to consider in determining the disability. Courts require that long term disability carriers give attention to subjective complaints, assign weight to those subjective complaints or provide specific reasons for its decisions to discount those subjective complaints.

Carriers simply can’t point to a lack of objective evidence in denying a claim. The carrier has to identify any objective findings and consider the cognitive symptoms that would reasonably be expected to see as a result of the medical condition. Carriers can’t just rely on the lack of objective evidence to deny a claim unless there is a subjective, self-reported symptoms and limitations clause in the policy.

What you should do if you have cognitive dysfunction

If you’re filing a long term disability claim as a result of cognitive dysfunction, you should obtain a copy of your medical records and review those records closely. Will your physician document the medical evidence for your cognitive dysfunction or clinical correlation between the complaints and your diagnosis? Has your physician performed any objective testing? Has your physician explained how your cognitive difficulties are manifestations of the symptoms of your medical condition? If not, you may claim may be denied right out of the box because of the lack of medical evidence that supports your cognitive dysfunction.

What should I do if I’ve been denied benefits as a result of cognitive disorder?

Contact Long Term Disability lawyer Nancy Cavey within 180 days of receipt of your denial letter so she can obtain the carrier’s file, conference with your doctor and obtain the necessary medical evidence to establish objective basis of your cognitive disorder and help you get the benefits you deserve. Contact her today at 727-894-3188.

What Every Erisa Plan Holder Needs To Know About Plan Amendments

erisa law lawyer disability tampa

If you employer offered you a disability policy, you may be covered by the Employer Retirement Income Security Act (ERISA). ERISA governs both pension benefit plans and long term disability benefits. ERISA long term disability plans are amended for one reason or another. Amendments can be classified into two categories, substantive and procedural.

Substantive and Procedural Plan Amendments

If a benefit is changing or ending, this would be considered to be a substantive. However, if only appeal procedures such as deadlines for submitting an appeal or for decision-makers to make the final decision on a claim, that’s probably a procedural amendment.

The general rule is that procedural amendments are generally not retroactive. However, substantive amendments will affect you if you’ve vested in your benefits.

How Plan Amendments Must Be Made

Plan sponsors have to follow the ERISA statute to make sure that the amendment has been made properly. The reality is the plan amendments can be made into effect whether it is good or bad.

Learn more about your policy

You can learn more about your disability policy by ordering a free, no obligation copy of our ERISA disability book , Robbed of Your Peace of Mind, today by visiting this link: to understand more about ERISA disability and your options.

Why Discovery Is Limited In Erisa Cases

discovery erisa disability limited

If you purchased a long term disability policy through your employer, your long term disability policy may be governed by the Employer Retirement Income Security Act (ERISA).

If you’re a long term disability policy holder whose benefits have been denied, you can challenge that denial in a federal court. However, you or your lawyer’s rights to conduct discovery and take the deposition of a claims adjuster, peer review doctors or others is generally limited.

discovery erisa disability limited

Why’s Discovery limited?

The fundamental goal of ERISA is to provide a “method for workers and beneficiaries to resolve disputes over benefits inexpensively and expeditiously.” Accord Semien v. Life Ins. Co. of N. Am., 436 F.3d 805, 815 (7th Cir. 2006). Consequently, discovery is often limited in an ERISA case. Discovery beyond the administrative record (the carrier’s file) is generally inappropriate depending on the court’s applicable standard of review.

What’s the standard of review?

A denial of ERISA benefits is reviewed under a de novo standard unless the benefit plan gives the administrator or fiduciary discretionary authority to determine eligibility for benefits or to construe the terms of the plan. Firestone Tire & Rubber Co. V. Bruch, 489 U.S. 101, 115 (1989).

However, when the challenged plan grants the administrator discretionary authority under the applicable standard of review is “arbitrary and capricious.” An administrator’s interpretation of the plan “won’t be disturbed” if reasonable. As a result, a long term disability carrier has the power to review the medical and come to its own determination as to entitlement to benefits.

That’s not good for you! What are examples of discretionary language? Some examples include the following:

“_______X_______carrier shall possess the authority, in its sole discretion, to construe the terms of this policy and to determine benefit eligibility hereunder. _______X______’s decisions regarding construction of the terms of this policy and benefit eligibility shall be conclusive and binding.”

Therefore, based on the language and controlling law, the federal court would have to apply the “arbitrary and capricious” standard of review which results in a limited review of the administrative record and even more limited ability to conduct discovery.

What should I do if my claim for disability benefits has been denied?

If your claim for disability benefits has been denied, please give us a call immediately to look over your denial. You may need a lawyer to get the disability benefits you deserve! 727-894-3188

Group Health Insurance Benefits For Those On Long Term Disability Insurance

group health insurance long term disability attorney

When you became disabled you, unfortunately, most likely lost your job and your group insurance benefits. The lack of health insurance can have a devastating impact on your medical and financial future.

group health insurance long term disability attorney

Websites for help with insurance

Did you know that there are a number of websites that can help you find an affordable insurance program? These include the following:

• The official site for the Health Insurance Marketplace (a.k.a. Obamacare);

• A new site from the Robert Wood Johnson Foundation to help consumers learn about credits and subsidies for health insurance;

• Solid information on both Medicare and the Health Insurance Marketplace

• Florida The online home of Serving Health Insurance Needs of Elders (toll-free 1-800-963-5337); and

• The official site for Medicare information.

Don’t delay! If you need insurance, help is available today.

If your Long Term Disability claim or Social Security Disability claim has been denied, contact attorney Nancy Cavey who can help you get the benefits you deserve.

Discretionary Clauses And Your Long Term Disability Claim

Discretionary Clauses long term disability claims

Get out your long term disability policy and look for something called the “Discretionary Clause”. It’s a clause that lets the long term disability carrier make the decision and requires that the court defer to its decision. It’s what I call a “get out of jail free card.”

Fortunately, there are some states that prohibit discretionary clauses in long term disability policies. These states include:

Michigan; and

You can determine whether the discretionary clause is applicable to you by looking at your disability policy and what state your policy was issued.

What other terms don’t you want to see in your long term disability policy?

Long Term Disability lawyer Nancy Cavey has written a go-to guide, “Everything You Need to Know About Your Long Term Disability Claim” that talks about all of the terms that you don’t want to see in your long term disability policy. You can order a free, no obligation copy of her book by contacting Long Term Disability lawyer Nancy Cavey at 727-894-3188.

Making The Decision To Hire An Attorney To Get Your Long Term Disability Benefits If Your Claim Has Been Denied

hiring a long term disability attorney

You bought your long term disability policy to provide you and your family peace of mind if you were unable to work. You’ve even made the difficult decision to apply for disability benefits knowing that your physician and employer have supported your claim. Yet, you’ve gotten a denial from the long term disability carrier.

No matter how angry or upset you are, don’t walk away from your long term disability claim. As a disability attorney, I know that very few people look forward to protracted litigation but there are times in life when the only right course of action is to pursue your claim.

hiring a long term disability attorney

What you should do if your claim has been improperly denied

If your insurance company improperly denied or treated your claim with a total lack of regard, it’s time to get a long term disability attorney involved.

When you’re forced in that position, you want to make sure that you’ve hired the right long term disability attorney for you.

You can order your free, no obligation copy of my book, “Hiring the Right Long Term Disability Attorney for You” by contacting my office at 727-894-3188 for a free, no obligation consultation.

Only an experienced disability attorney can understand the terms and conditions of your policy, the reasons for your initial denial and outline and implement a strategy for getting the long term disability benefits you deserve. After all, you purchased your disability policy to provide you and your family peace of mind. Don’t let the long term disability carrier rob you blind! Call us today to discuss your options – 727-894-3188.

The Five Things Long Term Disability Carriers Try To Do To Complicate And Even Deny Your Long Term Disability Benefits

5 things long term disability insurance carriers do

I’m sure that you purchased your long term disability policy to provide peace of mind if you became disabled. You may have every intention of returning to work but simply continue to be disabled while you’re recovering.

5 things long term disability insurance carriers do

Don’t think that the long term disability carrier is sitting idly by while you’re collecting disability benefits. There are five things that long term disability carriers can do to delay or even deny your long term disability benefits. These include:

1. Obtaining an Independent Medical Evaluation (IME) by a physician who has been paid to say that you are not disabled;

2. Having a field investigator knock on your door, unannounced, for the purposes of taking a statement about your Activities of Daily Living;

3. Seeing strange vehicles in your neighborhood following you to and from doctor’s offices, the grocery store or even to the children’s school and securing surveillance of your activities;

4. Contacting your neighbors and even your co-workers about your hobbies and daily activities;

5. Having the long term disability carrier’s peer reviewer or consulting doctors call your attending physician in an effort to convince your doctor that you’re capable of engaging in part-time employment.

What you should do to protect yourself

One of the quickest ways to provide yourself with peace of mind is to secure the services of an experienced long term disability attorney who can:

1. Help you complete the Activity of Daily Living forms submitted to you by the disability carrier;

2. Provide advise on what to expect and how to handle field representatives, surveillance and vocational evaluations used by disability insurance companies to deny claims;

3. Provide disability advice on what to expect and how to handle an independent medical evaluation (IME) or a Functional Capacity Evaluation (FCE);

4. Advice on how you should communicate with your physician about your occupation and how to fill out the disability forms;

Getting the go-to book

You should also order the no obligation copy of my book, “The Smart Long Term Disability Consumer Guide For Preparing For Your Statement and Field Visit – See more at:” that explains to you the games that long term disability carriers play in disability claims.

Be prepared and be forewarned. You should be ready to take on insurance companies so that you can get the disability benefits you deserve. Call today at 727-894-3188 for a complimentary consultation.

Should I Handle My Own Long Term Disability Claim?

handle your own disability claim

Sure! Anyone can handle their own disability claim. However, it is rare for those who are unrepresented to be successful in an appeal to get the disability benefits they deserve.

Long term disability attorneys, such as Nancy Cavey, have the knowledge and experience to handle your long term disability claims.

Unfair carrier tactics

Many long term disability carriers will often take advantage of policy holders by employing unfair tactics to delay and deny your claim. They’ll ask for the same information over and over, contact your doctors needlessly and drag their feet before making a decision on your claim.

Having a long term disability attorney can put you on an equal footing. It sends the carrier a message that you’re serious about the handling, preparation and presentation of your long term disability claim. They know that you’re determined to get the long term disability benefits you deserve.

Be sure to check out our long term disability guide, “Robbed of Your Peace of Mind” written by our very own Nancy Cavey. This book is a useful tool when trying to navigate the long term disability claims process.

How To Deal With Erisa Disability Insurers Claims And Reimbursement For Social Security Overpayments

overpayment ERISA disability lawyer

Many Long Term Disability plans provide that the policy holder must properly refund any lump sum retroactive Social Security Disability payment and send the overpayment amount within 30 days of the receipt of the notice from the Long Term Disability carrier. If you fail to make reimbursement, many carriers will claim reimbursement of the overpayment of disability benefits that occur due to your receipt of Social Security benefits pursuant to 29 U.S. Code Section 1132(a)(3).

In Great – West Life and Annuity Insurance Company v. Knudson, 534 U.S. 204(2002), United States Supreme Court addressed a carriers’ right to enforce a reimbursement provision in an ERISA plan.
In Knudson, the carrier paid Ms. Knudson’s medical expenses and then filed a law suit in state court to recover damages, as a result of her motor vehicle accident. The funds that were recovered in the tort action were paid into the Special Needs Trust and Great Life filed an action in court asking for reimbursement of the sums it had paid out on her behalf from the Special Needs Trust.

overpayment ERISA disability lawyer

The U.S. Supreme Court held that whether the carrier was entitled to reimbursement on a legal or equitable basis depended on the nature of the Plaintiff’s claim and the underlying remedies claimed. The court held that if restitution was equitable in nature, the Long Term Disability carrier’s action had to seek, not to impose personal liability on the policy holder, but to restore the funds or property in the policy holder’s possession. Because the monies had been placed in a Special Needs Trust, the court held that the monies were not in the policy holder’s possession.

The practical result of the Supreme Court opinion is that the carrier has to prove the amount that is due, establish that they’re entitled to reimbursement on an equitable basis and establish that the policy holder has the funds in their possession.

If these three things are not established then the carrier is generally, not entitled to reimbursement.

However, that doesn’t mean you’re off the hook. A Long Term Disability carrier can reduce your future benefits by the receipt of the overpayment and will, generally, reduce your benefits until they have received the full amount of the overpayment. The end result? Long Term Disability carriers get their money back one way or another.

What should I do if the carrier is claiming an overpayment?

Contact Overpayment Long Term Disability Benefits attorney Nancy Cavey today to learn more about whether the carrier is, in fact, entitled to reimbursement, strategies for dealing with the reimbursement claim and causes of action that may arise, as a result of collection activities on behalf of the carrier. If the carrier has hired a collection agency that’s harassing you regarding overpayment, there might be a Fair Debt Collection Practice Act (FDCPA) or state consumer violation that can help resolve the overpayment issue favorably for you!

How Do Long Term Disability Carriers Use Position Statements To Deny Fibromyalgia Claims?

long term disability carriers position

Many long term disability carriers are in the business of collecting premiums and not paying benefits to fibromyalgia policy holders. Many long term disability carriers will deny fibromyalgia claims on the basis that fibromyalgia is largely based on self reported symptoms and that there isn’t any objective evidence of restrictions and limitations.

long term disability carriers position

It’s not uncommon to see a denial letter language that describes fibromyalgia syndrome as a functional somatic syndrome. The denial language will say that FMS sufferers symptoms are “exacerbated by a self-perpetuating, self-validating cycle in which common, endemic, somatic symptoms are incorrectly attributed to serious abnormality, reinforcing the patient’s belief that they have a serious disease.” Barsky A. Borus J: Functional Somatic Syndromes (review). Ann Intern Med. 1999: 130:910-921.

Further, the long term disability companies will cite to an outdated study in the Journal of Rheumatology of 1996 called the “FMS Consensus Report.” The outdated report concludes that “only a minority of FMS patients are unable to work.”

Long term disability carriers use this study to justify claims denials on the basis that “at a minimum, FMS claimants should be able to perform sedentary or light work.”

If your claim for long term disability benefits has been denied, contact fibromyalgia long term disability attorney, Nancy Cavey, at 727-894-3188 who can help you get the benefits you deserve no matter where you live in the United States.