Winning Disability Insurance & ERISA Claims
The denial of an ERISA or disability insurance claim is devastating. People who are totally disabled can’t earn money to support their family or themselves, and desperately need their disability benefits.
Despite this, insurers and plan administrators routinely deny valid claims. They do not limit their denials to hard-to-prove illnesses like fibromyalgia, chronic fatigue, myofascial pain syndrome, back pain and depression.
Even clients with terminal illnesses such as cancer have needed Stennett & Casino’s help to obtain benefits.
If your ERISA or disability insurance claim was denied or payment has been long delayed, the San Diego Law Office of Stennett & Casino can help you.
We only represent individuals and we have years of experience in obtaining the benefits owed to our clients by disability insurance carriers and ERISA plans.
Speak with an experienced attorney and get valuable insights today. Call 619.544.6404 or use our easy forms throughout the site to ask us a question.
John Stennett and Barbara Casino have years of experience in successfully handling disability claims. A quick perusal of the below listed cases reflects a sampling of STENNETT & CASINO’s numerous successes and highlights the issues that arose in those cases.
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 applied for disability and was 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 Stennett & Casino for help. 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.
Stennett & 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 sought our help. 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 Stennett & Casino was 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.
By hiring Stennett & Casino, our client received additional benefits totaling $346,775.00.
The insurance company after having her examined by their own rheumatologist determined that our client was able to perform 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 measurable 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 opined that her ability to function would gradually become much more limited. The insurance company’s doctor summarized these findings to the insurance company and even with these observable limitations, the insurance 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 from the specialist confirming her total disability. The 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 a lawsuit 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.
The City of San Diego provides Disability Retirement Plans to employees that differ from private sector plans. San Diego City employees are provided with two levels of Disability Insurance Benefits:
- Industrial Disability Retirement – If your disability is work related, you are entitled to greater benefits from the date of disability regardless of your age.
- Non-Industrial Disability Retirement – If your disability is not related to your employment, you are entitled to benefits beginning at age 55.
The criteria for a member to be considered for Industrial Disability Retirement is to be permanently incapacitated by bodily injury or illness caused by their job; are unable to perform the usual duties of their job; and are required to retire. If awarded, an industrial disability retirement benefit is the higher of the following amounts:
- 50% of your highest one-year salary; or
- If you are service eligible, your service retirement benefit.
The employee is also offered federal tax benefits available to disability retirement recipients.
However, if the employee has at least 10 years of creditable service and is found to have become permanently incapacitated by a non-work related injury or illness; is unable to perform your usual job duties and is required to retire; they may be eligible for a Non-Industrial Disability Retirement. If awarded, the retirement will be the highest of the following amounts:
- 33 1/3% of your highest one-year salary; or
- 1.5% x number of years of service x highest one-year salary; or
- If you are service eligible, your service retirement benefit.
There are no federal tax benefits associated with a non-industrial disability retirement.
As you can see, the employees have a tremendous amount of future earnings and tax implications at stake.
Case History and Ruling
Our client began her employment with the City of San Diego approximately 20 years ago as a sanitation worker. Her job was considered heavy labor in that she had to lift and drag garbage cans weighing anywhere from 50 to 100 pounds on a frequent basis. The job also required her to climb in and out of the truck and climb up and jump off the rear step of the truck. These activities were done repetitively in the course of the day.
Within five years of the date that the client began employment, she suffered an on the job injury to her lower back which continued to be problematic all through her employment. In addition, the repetitive jumping and climbing caused her to suffer injury to her feet requiring several surgeries. Both injuries disabled her from returning to her position with the city. The client made a claim with the city for disability retirement benefits dating back to 2006. The city denied her claim alleging that the back injury was not disabling and the injury to her feet was due to a pre-existing condition (flat feet).
Stennett & Casino took the case through judicial hearing and through cross examination of the city’s doctor and reports from the treating doctors were able to prove that both the back and feet injury were disabling and both were related to her employment. The client received an award of $104,000.00 in past due benefits. that differ from private employer plans. They provide two levels of Disability Benefits. If your disability is not related to your employment, you are entitled to benefits beginning at age 55. If your disability is work related, you are entitled to greater benefits from the date of disability regardless of your age.
Our client was a financial analyst for a large defense contractor. She had to stop work due to severe symptoms related to her diagnosis of Lupus. Lupus is an autoimmune disease in which the immune system attacks one’s own body. Our client was treated with medication to suppress her immune system, which exposed her to other illnesses and infections which her suppressed immune system could not fight.
The client had disability insurance with MetLife through her employer. MetLife paid benefits for 2 years then cut her off after having her examined by its own physician. MetLife’s physician reported that client “could probably” perform the tasks of sedentary work; however, he qualified his opinion by stating that with her extensive problems, he did not know whether she could function within the average stress of a workplace. MetLife ignored the opinions of all treating physicians who supported her disability claim and instead relied on the ambiguous report of its doctor.
After we filed a lawsuit on behalf of our client and took the case to trial, a Federal judge agreed that MetLife abused its discretion in denying ongoing disability benefits. The court questioned why MetLife would pay benefits and then subsequently terminate benefits without a showing of improvement of her medical condition; questioned why MetLife totally ignored the opinions of the treating physicians and instead relied on the ambiguous and equivocal opinions of its doctor; the court awarded the client back disability benefits, attorney’s fees and the entitlement to future benefits.
To review the court’s entire 30-page opinion, see Watts v. Metropolitan Life Insurance Company, 2011 U.S. Dist. LEXIS 44805.
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 successfully returned to the workforce and 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 programmer and manager, his back finally gave out, precluding him from working full time. He applied for and received long term disability benefits.
Four years later, on December 23rd, the insurance carrier placed our client under video surveillance. The video showed him Christmas shopping with his wife for several hours. Client was driving with his specially equipped vehicle, getting in and out of his car into his wheelchair and going to various stores. Based on the video and client’s refusal to take constant pain medication, his benefits were terminated. Stennett & Casino had our client tested through a Functional Capacity Evaluation and had his doctor prepare additional reports; however, the insurance company refused to pay additional benefits. We filed a lawsuit 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.” The court’s opinion can be found at Robertson v. Hartford Life and Accident Ins. Co.
Four years later, on December 23rd, the insurance carrier placed our client under video surveillance. The video showed him Christmas shopping with his wife for several hours. Client was driving with his specially equipped vehicle, getting in and out of his car into his wheelchair and going to various stores. Based on the video and client’s refusal to take constant pain medication, his benefits were terminated. Stennett & Casino had our client tested through a Functional Capacity Evaluation and had his doctor prepare additional reports; however, the insurance company refused to pay additional benefits. We filed a lawsuit 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.” The court’s opinion can be found at Robertson v. Hartford Life and Accident Ins. Co.
The Ninth Circuit Court of Appeals in Salomaa v. Honda LTD Plan 637 F.3d 958 found that CIGNA’s Insurance Company’s decision to deny disability benefits to a claimant with chronic fatigue syndrome was illogical, implausible and without support because:
- Every doctor who personally examined the insured concluded that he was disabled;
- The Plan Administrator demanded objective tests to establish the existence of a condition for which there are no objective tests;
- The Administrator failed to consider the Social Security Disability Award;
- The reasons for denial shifted as they were refuted, were largely unsupported by the medical file, and only the denial stayed constant;
- The Plan Administrator failed to engage in the required “meaningful dialogue.”
The Court found that in a disability claim that turned upon subjective evidence, such as the amount of a claimant’s pain and fatigue, it was an abuse of discretion for the insurer to rely solely upon doctors who merely reviewed the records without examining the patient when there was a uniformity of agreement by treating physicians what the individual was disabled.
Another important feature of the case was the Ninth Circuit confirming that CIGNA’s physician report is one of the documents that the Plan is required to provide the claimant as part of its duty to provide a full and fair review. Most importantly, the Court held that these physicians’ reports must be provided prior to a final determination. This allows the claimant or his/her physician to comment on or rebut the insurer’s physician report prior to a final determination on appeal.
She filed a claim for disability benefits with Standard Insurance Company. They paid her benefits for a year and a half when her benefirs were terminated. She hired Stennett & Casino to handle her appeal.
It was obvious to us that our client suffered a traumatic brain injury. In order to prove her disability we had her undergo neuropsychological testing. The testing supported her injury.
Stennett & Casino submitted the testing as part of her appeal. As a result Standard Insurance reopened her claim and paid the benefits owed her under her disability policy.
Our client came to us after having been paid disability benefits for 5 years by Reliance Standard due to a back injury. The doctors were unsuccessful in treating her condition which left her in constant pain. As a result she developed what was diagnosed as a Chronic Pain Syndrome with symptoms of depression and anxiety. This resulted in Reliance Standard terminating her disability benefits claiming that her disability was contributed to by a mental disorder – depression and anxiety.
Stennett & Casino had to file suit and go to trial on behalf of our client on this issue. We were successful in convincing the court that 1) the client’s back pain was the cause of her depression; 2) the disability policy was ambiguous, and; 3) that the mental illness limitation did not apply to mental conditions arising from a physical disability. Our client received a judgement for the payment of all back benefits owed and entitlement to future disability benefits. The court’s opinion can be found at Jarillo v. Reliance Standard Life Insurance Co., 2017 U.S. Dist. Lexis 59928.
We have helped clients with claims against almost every disability insurance company. We’ve had repeated successes, both in court and out of court, in obtaining benefits from:
- UNUM/Provident
- Standard
- Metropolitan Life
- Prudential
- Hartford
- Pilot Life
- Paul Revere
- CIGNA
- CNA
- Life Insurance Co. of North America (LINA)
- Mass Mutual
- Sunlife
- United of Omaha – Mutual of Omaha
- Aetna
- reliance standard
- Jefferson Pilot
- Sedgwick
- Canada life
- AIG
- liberty mutual
- Reliastar
- Lincoln financial
If you would like more information on our cases involving disability insurance & ERISA claims,
please visit our success stories section for a review of past cases.
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