Success in ERISA Claims and Other Insurance Claims

The cases below are just a few of our successes in representing clients whose ERISA or other insurance claims were denied. We've chosen these cases to show the type of insurance claim problems we routinely handle for our clients. These links jump to the starting point in the text for each category of examples:

• Disability Claim Denials
• Life Insurance Claim Denials
• Fire Insurance Claim Denials
• Wrongful Death / Serious Injury Claims

The client was a director of underwriting for an insurance company. He had been in the business for 17 years. He sustained a knee injury in the mid 1990s that developed into reflex sympathetic dystrophy (RSD), a pain syndrome that is very difficult to treat. His condition worsened and his pain distracted him while working. His pain medications made him drowsy and made it difficult to concentrate. However, he was a hard working, dedicated employee who wanted to stay on the job as long as possible.

After undergoing two unsuccessful surgeries, the client was laid off and filed for disability benefits . The disability insurer denied benefits, claiming that the fact that he had stayed on his job proved that he was not disabled, and that he was laid off only because of a company-wide reduction in force. The insurer pointed out that the client had to be totally disabled on his last day of work in order to get benefits. During the administrative appeal process Stennett Casino documented through employment records, co-employees and the treating physician that the client's disability occurred before he was laid off. The insurance company continued to deny the claim and it eventually went to trial. The trial judge agreed with Stennett Casino and awarded our client disability benefits. Attorney's fees and interest were also recovered.

The client was a pharmacist for 32 years. His back began to bother him for the last six or seven years before he was unable to continue work. Pharmacists must be on their feet almost all day, and his back condition prevented him from standing more than twenty minutes at a time. The disability insurer denied benefits after doing a job survey to determine that other employers ( though not our client's) would allow him to use a stool to accommodate his back problem.

Stennett Casino retained a vocational expert who performed a more thorough job market survey and found that although employers by phone indicate they will accommodate a disability, when it comes down to actually hiring among several applicants, the disabled are often left out. Insurers cannot use theoretical jobs as a basis to deny benefits. They must look at the real world market place in determining if a disabled person can return to work. Based on our vocational expert's report and more thorough medical documentation of our client's physical limitations, we were able to conclusively document our client's disability, resulting in the insurer voluntarily paying disability benefits.

The client was a supervisor in the aerospace industry for 26 years. In May 2002, he became aware of increased fatigue, coughing, shortness of breath and irritation in his eyes and throat that interfered with his work. According to the doctor who treated him, the client's disability was due to a condition called RADS (reactive airways dysfunction syndrome) caused by his longtime exposure to toxic chemicals at his job. Evidence that he had RADS included his symptoms of achy joints and muscles, chronic fatigue, headaches, difficulty concentrating, irritation of the eyes, nose, ears, throat and skin, and hypersensitivity to odors, lights, sounds and temperature extremes.

The client applied for disability and was summarily denied. An insurance company doctor said all his symptoms were related to his asthma or the side effects from the various medications he took to control his asthma. This doctor only reviewed his medical records and never saw the client.

The client came to us. We contacted the doctor who was the client's pulmonary/ critical care specialist, asking him to comment on the insurance doctor's report. Our client's doctor refuted all of the opinions of the insurance company's doctor, and said the client was unequivocally, permanently disabled.

Stennet Casino appealed the decision of the insurance company, based on the strong medical report of the client's own treating doctor, and the client was awarded disability benefits.

The client had been employed for 8 years as a registered nurse at a local San Diego hospital. In July 1999, she was diagnosed with Stage IV metastasized breast cancer, and underwent a lumpectomy, chemotherapy, radiation and a bone marrow transplant. All of her doctors considered her to be disabled from work. She received disability benefits until 2002, when the insurance carrier abruptly denied her disability.

The client then sought our help. After investigating the matter fully, we found that the insurance company had misinterpreted her doctors' reports and violated its own claims manual when it denied her disability. That claims manual defined what internal rules, guidelines, protocol and criteria the insurance adjuster had to follow in evaluating a claim for disability. We found that the insurance company's own manual listed health conditions which, if confirmed, would give the client a presumption of disability. Metastasized breast cancer was one of those health conditions. Since this case was not bound by ERISA, we pursued not only the client's contractual rights but also damages for "bad faith" under California insurance law.

After a settlement conference, we were able to successfully settle the matter with the insurance company. Our client received her disability payments, plus additional money based on our evidence of the insurer's bad faith.

Our client was in a serious auto accident at the age of 22, which confined him to a wheelchair due to serious back injuries. Despite his serious disability, he returned to school to learn computer programming. He returned to the workforce and eventually became a program manager for Oracle Corp. Due to a combination of his serious back injuries and the wear and tear after 17 years of working as a computer programer and manager, his back finally gave out, precluding him from working full time. He applied for and received long term disablity benefits.

Four years later, on December 23rd, the insurance carrier placed our client under video sureillance. The video showed him Christmas shopping with his wife for serveral hours. Client was drving with his specially equipped vehicle, getting in and out of his car into a wheelchair and going to various stores. Based on the video and client's refusal to take constant pain medication, his benefits were terminated. We had our client go through a Functional Capacity Evaluation and had his doctor prepare additional reports; however, the insurance company refused to pay additional benefits. A lawsuit was filed in Federal Court and the court found in our client's favor. In referencing the surveillance video the court noted that "the plan does not require a claimant to be utterly helpless in order to be eligible for disability benefits... and plaintiff would hardly be the only person overtaxing his abilities when shopping on December 23rd."

Our client was employed as the Clinical Director of a medical research company whose job was classified as sedentary, even though it required her to travel. In 1999, she developed a neuromuscular disorder which became progressively debilitating and eventually totally disabeld her from work. Her condition was considered to be permanent and had not treatment or cure.

The insurance company after having her examined by their own rheumatologist determined that our client was able to preform sedentary work. Their doctor's report of the examination confirmed that our client had difficulty walking up and down the hall, used a cane, had difficulty getting out of a chair and had measuralbe moderate weakness in all the muscles of her upper and lower extremities. Their doctor further reported tenderness in her lower back, swelling in her knees, an inability to perform repetitive grasping and opinioned that her ability to function would gradulally become much more limited. The insurance company's doctor summarized these findings to the insurance company and even with these observable limitations, the insuracne company continued to deny her disability.

When our client retained us, we immediately informed the insurance carrier that the client was being seen by a neuromuscular specialist and submitted a report fro mthe specialist confirming her total disability. Te report reiterated the fact that the disease was progressive. The insurance company refused to consider this report and refused to reconsider their denial of benefits.

Stennett Casino filed suit against the insurance company and was successful in getting the client all of her past due benefits, interest on those benefits and attorney fees as well as having her future monthly benefits reinstated.

Our client received a letter from her Disability Insurance Company offering to buy out the future benefits owed to her under her disability policy. In that letter, a lump sum of money was offered and she was told that the Insurance Company would pay a minimal amount to have an attorney review the offer.

Stennett Casino were retained and reviewed the client's entire disability claim. Through our review we discovered that the Insurance Company had been paying our client the wrong monthly benefit for the last five years. We convinced the Insurance Company that they underpaid our client $27,755.00 in benefits. In addition, we negotiated the buy out of her future benefits and our client received $9,000.00 more than what was originally offered.

By hiring our firm, our client received additional benefits totaling $36,775.00

An accidental death insurance policy will pay benefits when the insured dies as a result of an accident. But when the insured dies in an auto accident with a high blood alcohol rate - is that an accident? That was the issue in a recent case we handled in which our client's husband died in a single car accident while driving home from his brother's house after having a few beers. The insurance company argued that since the husband had intentionally consumed alcohol and intentionally driven home knowing he was drunk and knowing the dangers of drinking and driving, that his resulting accident was not accidental.

Only an insurance company could argue that an accident was not an accident under their policy. Though everyone knows what an accident is, it becomes mysterious when it comes up in court. Unfortunately there are cases on both sides of this question. However, we were able to argue common sense, the evidence of the case and the law to prevail for our client.

The 59-year-old mother of our client died of an accidental overdose of her medication, Oxycodone. The mother was insured with an accidental death policy; however, our client's claim for benefits following her mother's death was denied.

The insurance company denied the claim under the exclusion for losses caused by illness or the treatment thereof. It asserted that Oxycodone was a treatment for chronic pain and thus excluded by the policy provisions.

We argued that California Insurance Code §10369.12 precluded an insurance company from excluding a loss caused by prescription drugs. The court agreed with our interpretation of the Code and held that the exclusion was void as it applied to our case. Our client thus received the full value of the insurance policy plus attorney's fees.

The client's son died as a result of an accidental overdose of heroin. Our client, his father, was the beneficiary on the son's accidental death life insurance policy.

The life insurance company refused to pay the benefits, claiming the son's death was not "accidental." We filed a lawsuit.

In court, the legal question was whether it was reasonably foreseeable that a person would die from taking an illegal drug such as heroin. The insurance company pointed to cases from other states saying death due to overdose of cocaine was not "accidental."

We presented evidence that this was not a suicide attempt. The son was not a regular drug user and was scheduled to fly to St. Louis the next day to join his brother's family. We found governmental statistics showing that even among heroin addicts, the incidence of death by overdose was only .014%. This evidence convinced the court that the son's death was not reasonably foreseeable and was "accidental." The court judgment awarded our client the full amount of the death benefits plus interest and attorney's fees, all to be paid by the insurance company.

The client's husband died unexpectedly at age 48 after a massive heart attack. The insurance company denied her claim for her husband's life insurance benefits because he had not disclosed his history of high blood pressure on his life insurance application.

We first looked to see whether our client's deceased husband did not know or had forgotten about his high blood pressure when he filled out his application. If so, the insurer could not deny benefits on the grounds of the non-disclosure. However, when we obtained the insurance company's records, we found the insurer knew from its own medical examination that our client's husband weighed over 300 pounds and had high blood pressure and an abnormal EKG. Therefore, the insurance company was not misled by the husband's failure to check the box on the application indicating high blood pressure, and it could not deny our client's claim.

The client's husband died in an auto accident when a faulty gas tank ruptured and fire engulfed his car. The insurance company refused to pay her the accidental death benefits because of an exclusion in the husband's life insurance policy of coverage for losses occurring when one is driving while under the influence of an intoxicant. Here, an autopsy found morphine in the deceased husband's blood.

We investigated, and found that the morphine was a byproduct of the pain medication (Tylenol with Codeine) prescribed for the husband for his back condition. We pointed out to the insurance carrier the California Insurance Code prohibits an insurer from denying an accidental death claim based on the deceased's use of prescribed medications. The insurer continued to deny the claim. We filed an ERISA lawsuit on behalf of our client. We took the case to trial and our client was awarded a money judgment.

The client bought his home and a homeowner's insurance policy in 1993. The insurance company's agent placed $180,000 in dwelling coverage on the home without inspecting it. The homeowner questioned his agent because he had paid much more for the home. The agent assured him that $180,000 was sufficient to rebuild the home, and said the homeowner also had nothing to worry about because he had "guaranteed replacement cost" coverage.

After a fire destroyed his home, the homeowner discovered that rebuilding it would cost $385,000. Making matters worse, his insurance company claimed he no longer had "guaranteed replacement cost" coverage, saying it was taken away by a policy amendment buried in a renewal notice sent to the homeowner eight months before the fire. Of course, the homeowner had no documentation of this because the fire destroyed all of his possessions.

When the client retained us, we tried to persuade the insurance company to pay his full home rebuilding costs on two grounds. First, the agent had assured our client that $180,000 was enough to rebuild the home. Second, our client was still entitled to "guaranteed replacement cost" because the insurance company had not complied with the law requiring it to give the our client, the homeowner, "conspicuous notice" if it reduced his insurance coverage. The insurance company still refused to pay the full cost of rebuilding. We filed a lawsuit, and obtained a court award under which the insurance company not only had to pay the full cost to rebuild the home, but also additional amounts for loss of contents, landscaping, demolition, etc. The award totaled more than $700,000 - money our client then used to rebuild his home.

The client's husband left for work one morning in the company pick-up truck. He was driving north on I-15 when his vehicle suddenly went out of control, went off the road, and rolled over. He was ejected and died at the scene. His surviving wife, our client, was pregnant with their first child.

Our investigation uncovered the fact that the right rear tire tread had pealed off the truck tire. We retained scientific experts, who concluded that the defective tire caused the loss of control. We filed a lawsuit against the tire manufacturer. The tire manufacturer, after blaming everyone and everything but its own design for the tire failure, began pointing the finger at the truck manufacturer. The tire manufacturer contended the tire failed because it had been a spare, mounted by the truck manufacturer in a place where heat from the tailpipe damaged it. We settled the case before trial, and both manufacturers paid substantial amounts of money.

Our client was mother of an adult son who had suffered from polio his entire life. Although quadriplegic, he was able to survive using a ventilator that supplied air through a hole in his throat. Even though he was physically challenged, he was able to attend classes with assistance funded by his church. He had a good sense of humor, love of life, and fondness for people.

Our client's son required frequent suctioning of his lungs to keep him from suffocating on mucous. Because he could not breath on his own, the ventilator sounded an alarm when enough air was not being pumped into his lungs. This happened when the breathing tube in his throat was removed or malfunctioned, when his lungs needed suctioning, and when, after suctioning, the tube was not properly reinserted in the hole in his throat. This alarm system was vital to his life.

In May 1996 our client had to have surgery which required her to place her son (then 43) in a care facility specifically for high- maintenance patients. While at the care facility, our client's son died from lack of oxygen. His breathing tube had not been properly inserted, but the staff was unaware of this because they had turned off his ventilator alarm to keep it from disturbing other patients at night.

We represented our client for the wrongful death of her son. Through discovery both formal and informal, we proved that the care facility staff had turned off the ventilator alarm. We obtained a substantial settlement for our client. As part of our case, we pursued and were successful in having fines imposed against the facility for regulatory violations.

On July 18, 2004, Blanca was four and one-half months into her first pregnancy. She began having pains, causing her to go to the hospital with her husband Javier, where she was admitted. At approximately midnight that night, their child, Jesus, was stillborn. The stillbirth was devastating to the parents. After the stillbirth, Blanca held her baby and stayed with him until released the next morning. Her sorrow was so deep that she developed pains in her chest which she described as her heart being broken. The parents arranged to have their son buried at Greenwood Cemetery. They brought in clothing for their son, a blanket, teddy bear and prayer card to be placed in the casket. Greenwood personnel told them they would wash and dress their baby before placing him in the casket. The parents were at the grave site awaiting the burial ceremony when Blanca asked to view her baby one last time. After a flurry of activity it was discovered that there was no baby in the casket. A bucket containing a placenta was all that was found in the casket. Blanca was so distraught that she passed out at the grave site.

Later, a body was presented by the mortuary as the parents’ baby. DNA testing confirmed that the body was indeed their baby and a month later, a proper burial was given to their baby.

While awaiting DNA verification Blanca feared they may never find her baby. She became very depressed, remaining at home in the dark. She could not speak to anyone about the events. She eventually obtained counseling with her husband; however, the counseling sessions were very difficult, causing more anxiety and tremendous stress upon the marriage. Blanca was diagnosed with severe depression and post-traumatic stress syndrome for which she had to be medicated. There were points where she could not go on with therapy and points at which the marriage was in danger of dissolving.

The parents believed that both the hospital and Greenwood Mortuary were negligent - the hospital for failing to release their son to the mortuary driver and Greenwood Mortuary for attempting to bury the placenta in lieu of their son. The hospital settled with the parents. Greenwood Mortuary refused to acknowledge any responsibility.

Stennett & Casino took the case to trial. The jury found the mortuary responsible and valued the parents’ emotional distress damages at $600,000.00.