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.

How to Beat Insurance Companies in Court Who Deny Disability Insurance Benefits

Imagine 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 Process

While 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 Work

Sometimes 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.  

Faulty Disability Denial Letter?

If you received a letter from your disability insurance company denying your disability claim, then you should have an ERISA attorney look over the letter to let you know your rights.  You can call ERISA attorney Evan T. Engler by calling (614) 610-9988.

ERISA Claims Procedure - How Disability & Life Insurance Claims are Supposed to be Handled

The Employee Retirement Income Security Act of 1974 ("ERISA") was enacted by Congress to provide a comprehensive statute designed to protect employee benefit plans and pensions, among other things.  See Mertens v. Hewitt Assocs., 508 U.S. 248, 251 (1993).  Through ERISA, Congress wanted to ensure that if an employee was promised a benefit, then they would receive it.  Lockheed Corp. v. Spink, 517 U.S. 882, 887 (1996).  Employers are not required to establish employee benefit plans, but if they choose to do so, then they must abide by ERISA.  

ERISA provides a framework and set of minimum parameters through which an insurance company must administer an employee's claim for benefits for an employee benefits covered plan, such as for health insurance, disability insurance, or life insurance.  ERISA creates certain rules and obligations for fiduciaries of an ERISA plan.  In the ERISA context, a person is considered to be a fiduciary if they exercise "any discretionary authority or discretionary control respecting management of such plan ... ," or, any person who "has any discretionary authority or discretionary responsbility in the administration of such plan."  Basically, an ERISA fiduciary is the person who decides whether or not to approve or deny any employee's claim for benefits.  This is usually the insurance company's claim handler.  

ERISA establishes standards of conduct, responsibility, and obligations for fiduciaries of employee benefit plans, and ERISA provides for appropriate remedies, sanctions, and access to the federal courts.  Lockheed Corp. v. Spink, 517 U.S. 882, 887 (1996) (citing 29 U.S.C. §1001(b)).

ERISA requires every employee benefit plan to - 

(1) Provide adequate notice in writing to any participant or beneficiary whose claim for benefits under the plan has been denied, setting forth the specific reasons for such denial, written in a manner calculated to be understood by the participant, and 
(2) Afford a reasonable opportunity to any participant whose claim for benefits has been denied for a full and fair review by the appropriate named fiduciary of the decision denying the claim.

29 U.S.C. § 1133.

Minimum Requirement for Claims Procedures of Employee Welfare Benefit Plans

ERISA sets forth the minimum requirements for an employee welfare benefit plan in processing a claim for benefits, as codified in 29 C.F.R. § 2560.503-1.  This regulation provides, in excerpted and summarized part:

(1) Every employee benefit plan shall establish and maintain reasonable procedures governing the filing of benefit claims, notification of benefit determinations, and appeal of adverse benefit determinations;
(2) The claims procedures do not contain any provision, and are not administered in a way, that unduly inhibits or hampers the initiation or processing of claims for benefits;  
(3) The claims procedures contain administrative processes and safeguards designed to ensure and to verify that benefit claim determinations are made in accordance with governing plan documents and that, where appropriate, the plan provisions have been applied consistently with respect to similarly situated claimants;
(4) The claims procedures do not contain any provision, and are not administered in a way, that requires a claimant to file more than two appeals of an adverse benefit determination prior to bringing a civil action under section 502(a) of [ERISA];
(5) To the extent that the plan offers voluntary levels of appeal, including voluntary arbitration or any other form of dispute resolution, the claims procedures provide that:

(a) The plan waives any right to assert that a claimant has failed to exhaust administrative remedies because the claimant did not elect to submit a benefit dispute to any such voluntary level of appeal provided by the plan;
(b) The plan agrees that any statute of limitations or other defense based on timeliness is tolled during the time that any such voluntary appeal is pending[.]

ERISA basically lays out the minimum criteria that an insurance company who is providing benefits as part of an employee welfare benefit plan (usually in the form of health insurance, disability insurance, or life insurance) must abide by in deciding whether to admit or deny a claim for insurance benefits.  ERISA requires that insurance companies must establish reasonable procedures for the filing of benefit claims, they must notify the claimants of whether their claim was accepted or denied (which seems simple enough), the insurance plan cannot be so complicated as to make it hard to actually file a claim or get a claim processed, and the insurance company must make their decision to admit or deny a claim in a manner that is consistent with the actual terms of the insurance policy.  

If your claim for disability, health, or life insurance benefits has been denied, ERISA provides that the insurance company has to have an appeal process.  In ERISA cases, there are usually one or two administrative appeals before the claimant can file a federal ERISA lawsuit.  The administrative appeals are essentially just the submission of additional documentation supporting a claimant's rights to get the claim approved to the insurance company itself.  Then the insurance company decides again whether to admit or deny the claim.  ERISA mandates that insurance companies cannot require more than two administrative appeals before filing a federal lawsuit against the insurance company.  ERISA also generally requires that claimants exhaust their administrative remedies before filing a federal lawsuit.  Exhaustion of administrative remedies is a case law imposed requirement that simply means that a claimant has to first go through the administrative appeal process before filing a federal lawsuit.  ERISA requires that if there is a multi-step administrative appeal process (for example, one mandatory administrative appeal and then a second voluntary administrative appeal), then the claimant only needs to go through the mandatory appeal before filing a lawsuit and that the insurance company cannot argue in federal court that the claimant failed to exhaust their administrative remedies if the claimant did not elect to take an additional voluntary administrative appeal.

Minimum Requirements for Manner and Content of Employee Benefit Determination

When an individual's claim for health insurance benefits, disability insurance benefits, or life insurance benefits has either been approved or denied by the insurance company, the insurance company is required to send out a written notice to the individual, in a manner calculated to be understood by the individual, with the following information:

(1) The specific reason or reasons for the adverse benefit determination (benefit denial);
(2) Reference to the specific plan provisions on which the determination is based;
(3) A description of any additional material or information necessary for the claimant to perfect the claim and an explanation of why such material or information is necessary;
(4) A description of the plan's review procedures and the time limits applicable to such procedures, including a statement of the claimant's right to bring a civil action under section 502(A) of [ERISA] following an adverse benefit determination on review[.]

Appeal of Adverse Benefit Determinations

If an individual's insurance claim is denied by the insurance company, then ERISA requires that the insurance company establish and utilize certain processes and procedures to allow an individual to appeal an adverse benefit determination.  These requirements are, in summarized part:

(1) Every employee benefit plan shall establish and maintain a procedure by which a claimant shall have a reasonable opportunity to appeal an adverse benefit determination to an appropriate named fiduciary of the plan, and under which there will be a full and fair review of the claim and the adverse benefit determination.
(2) The claims procedures of a plan will not be deemed to provide a claimant with a reasonable opportunity for a full and fair review of a claim and adverse benefit determination unless the claims procedures -

(i) Provide claimants at least 60 days (or 180 days for disability insurance) following receipt of a notification of an adverse benefit determination within which to appeal the determination;
(ii) Provide claimants the opportunity to submit written comments, documents, records, and other information relating to the claim for benefits;
(iii) Provide that a claimant shall be provided, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to the claimant's claim for benefits;
(iv) Provide for a review that takes into account all comments, documents, records, and other information submitted by the claimant relating to the claim, without regard to whether such information was submitted or considered in the initial benefit determination.  

(3) Provide for a review that does not afford deference to the initial adverse benefit determination and that is conducted by an appropriate named fiduciary of the plan who is neither the individual who made the adverse benefit determination that is the subject of the appeal, nor the subordinate of such individual.

When an ERISA disability or life insurance claim gets taken to federal court, it is usually because the insurance company failed to properly follow the appeal procedures outlined above.

ERISA Appeal Attorneys

Evan T. Engler is an attorney at partner at the Columbus, Ohio based law firm of Harris & Engler.  Mr. Engler helps clients with their ERISA appeals at both the administrative and federal court stages.  If your claim for employee benefits (such as disability or life insurance) has been denied, then feel free to contact Evan T. Engler at (614) 610-9988 or This email address is being protected from spambots. You need JavaScript enabled to view it..  In ERISA cases it is critically important to get an ERISA attorney involved in the appeals process as early as possible in order to afford the best opportunity for getting benefit reinstated.
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