Disability Insurance Companies Denying Disability Insurance Benefits When Social Security Disability Was Approved

The United States Supreme Court ruled that insurance companies have a conflict of interest when they decide disability insurance claims that they themselves pay out.  In the case of Metro. Life Ins. Co. v. Glenn, 128 S.Ct. 2343, 554 U.S. 105 (2008), the Supreme Court found that there is a conflict of interest when an insurance company both decides whether or not to accept or deny a claim for disability benefits and also be the entity to either pay those benefits or save money by not paying those benefits.  

Most disability insurance plans have a requirement that if someone gets their claim for disability insurance coverage approved then that individual must also apply for Social Security Disability benefits.  Usually the insurance company itself pays for a law firm or company like Allsup to represent the individual in applying for Social Security Disability benefits.  Then if that individual gets accepted for Social Security Disability benefits, then the disability insurance company is entitled to set off whatever the individual receives from Social Security from the amount they have to pay in disability insurance benefits.  For example, if an individual is receiving $2,000 per month in disability insurance benefits and then they get approved for $1,500 per month in Social Security Disability benefits, then the disability insurance company gets to set off the SSDI benefits and only pay $500 per month.  

In Metro. Life Ins. Co. v. Glenn, the individual got approved by Metlife for long term disability benefits.  But then Metlife required the individual to apply for Social Security Disability benefits.  The individual was found to be permanently disabled and approved for Social Security Disability benefits.  Then when the disability insurance plan changed the definition of "disabled" after 24 months from 'unable to work at the employee's former job' to 'unable to work at any job,' Metlife denied the individual saying they could do sedentary work.  The Court found that the disability insurance company had a conflict of interest because they both decided when to accept or deny the claim for disability insurance benefits and they pay out those disability insurance benefits or save money by not paying them out.  The Court found that Metlife never properly reconciled their own conclusion that the individual could work other jobs with the Social Security Administration's conclusion that the individual couldn't work any other job.

When an individual is approved for SSDI and denied by their disability insurance company, the Court will look with a more scrutinizing eye at the insurance company's decision to deny disability insurance benefits.  

If your disability insurance benefits have been denied you should contact an ERISA disability insurance attorney.  Attorney Evan T. Engler is an ERISA disability lawyer and partner at the Columbus, Ohio based law firm of Harris & Engler.  Attorney Evan T. Engler helps individuals who have had their disability insurance benefits denied in Ohio, or the other Sixth Circuit states of Michigan, Kentucky, and Tennessee.

ERISA Disability Attorneys

"ERISA disability" means when you have private disability insurance through your employer.  ERISA is a federal law called the Employee Retirement Income Security Act of 1974.  You need an ERISA disability attorney when your application for disability insurance benefits has been denied or when you have been receiving disability insurance benefits but the insurance company has decided to stop paying your benefits for one reason or other.

Why Do You Need An Attorney For Denied Disability Claims?

The federal ERISA statute provides a specific set of guidelines and requirements that have to be met by insurance companies who are administering or deciding to deny your disability claim.  These requirements can make it hard for individuals to get their disability insurance benefits reinstated.  That is why if your disability claim gets denied, you need the experienced guiding hand of an ERISA disability attorney to guide you step-by-step through the process of trying to get your disabillity benefits back.

What Does An ERISA Disability Attorney Do?

An ERISA disability attorney knows the specific steps and procedures that must be done to give you the best chance to get your disability insurance benefits back.  Attorney Evan T. Engler is an ERISA disability attorney and partner at Harris & Engler.  Evan T. Engler has vast experience helping disability claimants appeal the denial of their disability insurance or otherwise getting payment for their denied disability benefits.  Attorney Evan T. Engler has been successful at every stage of getting his clients compensation for their disability claims, whether through appeals with the insurance companies themselves or by filing federal lawsuits against the insurance companies that wrongfully deny disability insurance benefits.

For ERISA disability cases, attorney Evan T Engler does not charge any attorney fees unless you get payment for your previously denied disability benefits.  If you don't get payment for your disability case, then you don't pay any attorney fees.  Evan T. Engler is a partner at the Columbus, Ohio based law firm of Harris & Engler and he helps clients whose disability claims have been denied across Ohio, Michigan, Kentucky, and Tennessee.  You can reach ERISA disability attorney Evan T. Engler by calling (614) 610-9988.  

ERISA Disability Insurers Frequently Try to Deny Claims Because of Alleged "Pre-Existing Conditions"

It happens all too often - an individual is unable to work because of a disabling condition, they fill out a disbility claim form, provide supporting medical documentation, and wait for the decision of the disability insurance company.  Then when the decision letter from the disability insurance company finally comes, the insurance company denies the claim because they say the claimed disability was actually caused by a pre-existing condition that was either before employment started or before the effective date of the policy.  There are only two choices for an individual in this situation: (1) give up and do nothing; or (2) appeal the decision to deny the disability claim.  If it is option number 2, then the individual should get a disability insurance attorney to handle the appeal.  If the cost of an attorney is a concern, then it shouldn't be.  The ERISA attorneys at Harris & Engler only collect a fee if you win your appeal or lawsuit.  If you don't win, you don't pay anything.  An individuals chances of success in appealing a denial decision is exponentially greater by hiring an attorney experienced in ERISA disability insurance denials.

Examples of Disability Insurance Denials for Pre-Existing Conditions in the Sixth Circuit and in Ohio

Having diabetes is a somewhat common reason for disability insurance companies to deny a later occurring more serious injury.  In the Sixth Circuit case of Collins v. Unum Life Insurance Company of America (2017), an individual had diabetes and one day tripped in his employers parking lot.  He fell and broke an ankle.  His foot later had to be amputated.  Unum Life Insurance Company denied his claim for long term disability coverage because they said it was his history of poorly maintained diabetes that was the reason his foot had to be amputated.

Unum denied coverage due to their disability insurance policy provision excluding from coverage any "accidental losses caused by, contributed to by, or resulting from ... disease of the body."

That case was similar to an Ohio disability case in Morgan v. United Omaha Life Insurance Company (S.D. Ohio, Mar. 11, 2001), where a few days after an individual stepped on a screw, the disability claimant went to the emergency room, where they were diagnosed with "diabetic foot infection," and their foot ultimately had to be amputated.  That disability insurance policy provided that the injury "must result in loss independently of sickness and other causes."  United Omaha Life Insurance Company denied the claim for disability insurance benefits claiming that the loss was not independent of sickness or other causes.  United Omaha ignored that there were infection issues after the initial surgery that led to the need to amputate the foot.

Another Sixth Circuit case that applies to Ohio disability insurance cases is Clark v. Metropolitan Life Insurance Company, 67 F.3d 299 (6th Cir. 1995).  In that case, the disability claimant filed a claim for disability insurance after having a left hip replacement.  Metlife denied the claim because they found a notation in a medical chart that the patient had pain in their left thigh for the past 4 -5 years.  Metlife said that because the pain in the thigh and hip was pre-existing before the surgery, that it was a pre-existing condition.  Metlife had a pre-existing condition clause that read:

"Expenses incurred as a result of an injury, illness, or pregnancy, as diagnosed by a physician or covered provider, which existed prior to the effective date of insurance are not covered by this plan, until twelve months from the effective date of your coverage of the plan, whether the condition was diagnosed before or after the effective date of insurance and whether or not the condition resulted in any symptoms prior to the date of insurance."

The Court did not side with Metlife in that case because the Metlife denial letter simply restated the medical names for the disability claimant's hip conditions, such as enthesopathy of the hip, traumatic arthropathy and osteoarthritis, and then just concluded that they were "pre-existing conditions."  The Court said that Metlife was required by statute and regulations to give the disability claimant specific reasons why it considered those conditions to be pre-existing.  See 29 U.S.C. Sec. 1133, and 29 C.F.R. Sec. 2560.503-1(f).

What to Do if Your Disability Insurance Claim Has Been Denied Due to Pre-Existing Conditions or Otherwise

The moment that you receive the claim denial letter from the insruance company, then the clock starts ticking for you to be able to do anything about it.  There are a lot of things that have to be done in a short amount of time to give you the best chance to overturn the decision to deny your claim.  If you don't do things the right way, then you can blow your chances at winning a lawsuit later on.  An ERISA disability attorney will take care of all those details for you.  Because disability insurance claims are most often governed under a federal law known as ERISA, you need to get an attorney who has specifically dealt with ERISA disability lawsuits before.  Evan T. Engler is an ERISA disability lawyer and partner at the law firm of Harris & Engler.  Harris & Engler is located in Columbus, Ohio, and attorney Evan T. Engler helps clients who's disability claims have been denied all across the Sixth Circuit federal court of appeals, which includes Ohio, Michigan, Tennessee, and Kentucky.  If you'd like to speak to an attorney about your denied disability claim, then ask to speak with Evan T. Engler by calling (614) 610-9988.

Denied Disability Insurance Coverage

You've received a letter from your disability insurance company that says that you will no longer be receiving disability insurance benefits, now what?  If your disability insurance company is saying that you're no longer disabled, you dont have to accept them at their word, you can get an ERISA disability attorney to fight to get your disability insurance benefits back.

What Should I Do After My Disability Benefits Get Denied?

The first thing to keep in mind after getting a letter from the insurance company that your disability benefits are being cut off is that there are tight time limits for you to do anything to try to reverse the denial decision.  This is why one of the first things you should do after getting your disability insurance benefits denied is call an ERISA disability attorney.  Most disability insurance companies allow or require you to appeal your disability denial with the insurance company itself before filing any sort of lawsuit.  

Attorney Evan T. Engler is a partner at the Columbus, Ohio law firm of Harris & Engler and he helps individuals in Ohio, Michigan, Kentucky, and Tennesee get their disability insurance benefits back.  Because there is only a short amount of time to put together your documentation to file with the disability insurance company, it is recommended that you contact an ERISA disability attorney as soon as possible after you receive your disability denial letter.

Denied Disability Claim Attorney

If your disability insurance has been denied then you need an ERISA disability attorney.  ERISA is a federal law that governs disability insurance, how appeals must be processed, and how the cases must be litigated.  Evan T. Engler is an ERISA disability lawyer and partner at the Columbus, Ohio based law firm of Harris & Engler.  Because ERISA is a federal law, Evan T. Engler helps individuals who have had their disability insurance benefits denied all across the federal 6th District Appeals Circuit, which includes Ohio, Michigan, Kentucky, and Tennesee.  You can reach Evan T. Engler to discuss your ERISA disability case by calling (614) 610-9988.  

Insurance Companies are Wrongfully Denying Disability Insurance Benefits Due to "Lack of Objective Medical Evidence..."

Disability insurance is supposed to replace your lost income if you are unable to work.  If your disability insurance is part of an employee welfare benefits plan with your employer, then a relatively unknown federal law called the Employee Retirement Income Security Act of 1974 (ERISA) governs your rights to disability insurance and the process that the insurance company has to use in order to determine whether to accept or deny your application for disability insurance benefits.

Insurance companies have been increasingly denying disability insurance benefits for people with chronic pain conditions like fibromyalgia.  "Fibromyalgia is a form of rheumatic disease with no known cause or cure.  The principal symptoms which are entirely subjective are pain and tenderness in muscles, joints and ligaments, but the disease is frequently accompanied by fatigue, sleep disturbances, anxiety, dizziness, irritable bowels and tension headaches."  Walker v. Am. Home Shield Long Term Disability Plan, 180 F.3d 1065, 1067 (9th Cir. 1999).  

Because complaints of pain and fatigue are hard to document on objective medical tests like MRIs, X-rays, or blood work, disability insurance companies are frequently denying disability benefits to their customers with diagnoses of fibromyalgia and other disorders that are hard to document and verify through objective medical tests.

The Sixth Circuit (the federal appeals court for Ohio, Kentucky, Michigan, and Tennessee) has recognized the difficulty of diagnosing fibromyalgia.  "Unlike most diseases that can be confirmed or diagnosed by objective medical tests, fibrositis can only be diagnosed by elimination of other medical conditions which may manifest fibrositis-like symptoms of musculoskeletal pain, stiffness, and fatigue."  Preston v. Sec'y of Health & Humas Servs., 854 F.2d 815, 817-19 (6th Cir. 1988).

What most often ends up happening is that a person will experience chronic pain symptoms over a period of time, and their primary care physician will send the patient out to see specialists to try to confirm or rule out various different diseases or disorders.  Fibromyalgia is sometimes the diagnosis after the rheumatologist has ruled out other possible diagnoses.  

Most of the treatment notes documented by primary care physicians and rheumatologists will simply document the patient's own complaints of pain and frequency of pain.  Then the disability insurance company requests medical documentation from the patient's primary care physician and rheumatologist and they will end up getting documentation that does little more than transcribe the patient's complaints of pain.  Then the insurance company uses these medical records against their own customers by denying the disability insurance claim with the explanation that there is no "objective" evidence of a disability, but only subjective medical documentation.

There are certain things that a person can do who has been denied disability insurance for fibromyalgia or other chronic pain conditions.  First, it is most helpful to consult with an ERISA attorney experienced in disability benefit denials for chronic pain conditions.  Most disability insurance plans allow either one or two chances to appeal the disability denial with the insurance company itself.  This is an absolutely critical time to talk to a disability attorney before you appeal with the insurance company.  If you have to file a lawsuit with an ERISA case, then you have to shore up your case at the administrative appeal stage in order to give yourself the best shot at winning at the district court stage.  

Attorney Evan T. Engler is a partner at the central Ohio law firm of Harris & Engler.  Evan T. Engler helps individuals with their ERISA governed disability and life insurance denials for cases located within the 6th Circuit (Ohio, Michigan, Kentucky, and Tennessee).  The 6th Circuit has been developing a few standards that tends to help individuals battling for their disability insurance benefits for chronic pain conditions like fibromyalgia.  You need to talk to an attorney experienced in disability insurance denials in order to give yourself the best show at getting your benefits.
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