How to Beat Insurance Companies in Court Who Deny Disability Insurance BenefitsImagine paying years worth of disability insurance premiums only to have the insurance company deny your claim for disability insurance benefits when you actually need it. For most people, disability insurance coverage is obtained through their employment as part of an employee benefits plan. If your claim for disability insurance benefits gets denied and the denial letter mentions the Employee Retirement Income Security Act of 1974 (ERISA), then it is time to get an ERISA attorney. Evan T. Engler is an ERISA attorney and partner at Harris & Engler and he helps individuals in Ohio who had their disability insurance benefits denied. Attorney Evan T. Engler handles ERISA cases at both the administrative appeal level within the insurance company itself and at the lawsuit level in federal court. Below are some of the main reasons why insurance companies get beat in federal court in the Sixth Circuit (which covers Ohio).
Disability Insurance Denial Is Not Based on Principled Reasoning ProcessWhile most decisions by insurance companies to deny ERISA disability benefits are reviewed by the Court on an arbitrary and capricious standard (which you can read more about here), the federal judge looks to see whether the decision maker at the insurance company does certain things. In order for a disability insurer's decision to deny disability benefits to be upheld in Court, the judge must be able to see that the decision to deny benefits was the result of a deliberate, principled reasoning process, and that the decision was made solely in the interest of the beneficiaries and for the exclusive purpose of providing benefits to beneficiaries. See Rochow v. Life Ins. Co. of N. Am., 780 F.3d 364 (6th Cir., 2015).
If in the letter from the insurance company denying disability insurance benefits the claims administrator merely restates the plan's terms and restates technical medical terms from the doctor's reports, and then basically says, without reasoning, "the documentation does not show that you are disabiled or cannot work full time," then that is simply not good enough. See Elliot v. Metropolitan Life Ins. Co., 473 F.3d 613 (6th Cir., 2006). The letter must "offer a reasoned explanation, based on the evidence for its judgment that a claimant was not "disabled" within the plan's terms. Id.
The Denial Must be Based on an Inability to WorkSometimes disability insurance denial letters just list plan terms and medical terminology and then basically say "we've determined that you cannot work full time." However, the insurance company will be found to have made a "reasoned judgment" only if it relied on medical evidence that actually assessed physical ability to perform job related tasks. See McDonald v. Western-Southern Life Ins. Co., 347 F.3d 161 (6th Cir., 2003); See also Quinn v. Blue Cross & Blue Shield Ass'n, 161 F.3d 472, 476 (7th Cir. 1998)) (the plan "was under a duty to make a reasonable inquiry into the types of skills [the claimant] possesses and whether those skills may be used at another job). Medical data, without reasoning, cannot produce a logical judgment about a claimant's work ability.
Many times for disability insurance claimants, the insurance company will send out a letter denying disability coverage that is loaded with medical and technical jargon but that does not provide any actual reasoning or logic for the reason behind the decision. Fortunately, if you've had this happen to you or a close loved one then this very lack of logic and reasoning can be used against the insurance company to get the decision to deny disability insurance coverage reversed.