tag:blogger.com,1999:blog-48036923532386099442024-03-13T03:54:31.104-07:00The Claimant's ERISA Blog: Applying For, Appealing and Litigating LTD Claims The long-term disability insurance process is unfair: individuals with claims know little, the insurance company knows a lot. The purpose of this blog is to reduce this imbalance by giving claimants the information they need to get the disability benefits they are entitled to. The blog will cover all claims under ERISA. Tell me what you need to know. More information at www.CtLTDLawyer.comDavid S. Rintoulhttp://www.blogger.com/profile/14474646582143975303noreply@blogger.comBlogger50125tag:blogger.com,1999:blog-4803692353238609944.post-83288748756051321842018-07-18T14:46:00.000-07:002018-07-18T15:09:31.382-07:00“See Attached:” Andy Rooney and The Two Most Important Words in Completing LTD Forms.<span style="font-family: "arial" , "helvetica" , sans-serif;"><br /></span>
<span style="font-family: "arial" , "helvetica" , sans-serif;">Andy Rooney used to have a regular humor segment on 60 Mintues complaining about <a href="https://www.youtube.com/watch?v=Q1lukmmJOHo&index=25&t=0s&list=PLgwVLGhHBUC5ECGjbOYg45tNkfC7lPQZa">minor annoyances of daily life</a>. I was never a fan: if you have airtime, why not complain humorously about the major issues with daily life rather than the size of paper towels, as he did in the link provided? One segment in particular stuck with me as an example of how trivial his complaints were: the whole segment was about forms that left too little space to fill in the information requested.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">Once I started helping Connecticut long-term disability claimants submit initial long-term disability claims, however, I realized that insurance companies can use small spaces on forms for their own advantage. In prior articles, <a href="http://ctltdlawyer.blogspot.com/2015/11/">here</a> and <a href="http://ctltdlawyer.blogspot.com/2017/11/When-Insurers-Ask-Doctors-for-Wrong-Information.html">here</a>, I’ve discuss the games insurance companies play in constructing their forms – creating a form that could lead to someone in a coma being found capable of performing a sedentary job - and ways to avoid the insurance company’s trap. The too-little-space problem Andy Rooney identified is easier to deal with that this - we can solve it with two words: See Attached.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">Most long-term disability claims are started with two forms: the claimant’s statement you complete, and the attending physician’s statement completed by your doctor. The forms request similar information: the impairment you suffer from; your job duties; and how your impairments prevent you from performing your job. </span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">The topics can be complex and require a lot of information to explain. But, the forms only give you a little space to explain them. Here are the relevant sections from one company’s form:</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;"><a href="https://3.bp.blogspot.com/-L1oO2oT0hHg/W0-xxSpls2I/AAAAAAAAQEw/SNajU6Ql5aMepQBkcTZtu2xxCGBfzIueQCLcBGAs/s1600/form%2Binsert.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="371" data-original-width="1495" height="156" src="https://3.bp.blogspot.com/-L1oO2oT0hHg/W0-xxSpls2I/AAAAAAAAQEw/SNajU6Ql5aMepQBkcTZtu2xxCGBfzIueQCLcBGAs/s640/form%2Binsert.jpg" width="640" /></a></span></div>
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<span style="font-family: "arial" , "helvetica" , sans-serif;">This is not a lot of room to describe the effect of a complex condition on a demanding job. You could write in<span style="font-size: xx-small;"> little letters</span>, but there is a better way: simply write “See attached” in the space, and then attached a document were you can describe everything in detail. Make sure you tell your doctor that he can put down “see attached” as well. The best things the doctor can attach are actual office visit notes, or tests results (MRI’s showing severe spinal stenosis or a neuropsychological exam documenting cognitive impairments), that demonstrate the vocational impairments resulting from your physical condition.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">The too-small-space problem arises in long-term disability benefit appeals as well, as the insurer will commonly require your doctors to prepare attending physician statements for the appeal. The forms are more important in initial LTD applications, though, because it might be your only chance to explain your condition and how it keeps you from doing your job. Even though you now know about the "See Attached" trick, using a lawyer who regularly works on initial LTD applications, and who knows through an active LTD benefit appeals practice what insurance companies need to see to establish disability from giving medical condition, can make it more likely that your first application will be successful. </span><br />
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David S. Rintoulhttp://www.blogger.com/profile/14474646582143975303noreply@blogger.com0Stamford, CT, USA41.0534302 -73.538734140.8618982 -73.8614576 41.2449622 -73.2160106tag:blogger.com,1999:blog-4803692353238609944.post-41594764792697234892017-11-10T06:59:00.000-08:002017-11-10T07:42:09.874-08:00Tricks Insurance Companies Play Part 2: When the Insurance Company Asks the Doctor for the Wrong Information<span style="font-family: "arial" , "helvetica" , sans-serif;">Previously, I <a href="http://ctltdlawyer.blogspot.com/2015/11/">wrote about</a> one trick insurance companies use to deny benefits, when they deceptively structure the attending physician’s form so the insurance company can claim it shows the patient can do the job, even though the doctor intended to state that the patient could not perform the job. A doctor could fill out the form properly for a bed-ridden paraplegic but the insurer could interpret it as allowing the person to perform a sedentary job. </span><br />
<span style="font-family: "arial" , "helvetica" , sans-serif;"><span style="font-family: "arial" , "helvetica" , sans-serif;"><br /></span><span style="font-family: "arial" , "helvetica" , sans-serif;">I recently saw another insurance company trick in a LTD ERISA appeal for a Westchester County client who was disabled by migraines. The basis for the denial was the same as I’ve seen in almost every case of disability based on migraines: the medical records did not address the frequency, duration and intensity of the headaches, so there was no proof the migraines were disabling. Given that this was the basis for the denial, in reviewing the claim file, I expected to see the insurer asking the doctors about the frequency, duration and intensity of the headaches. </span></span><br />
<span style="font-family: "arial" , "helvetica" , sans-serif;"><span style="font-family: "arial" , "helvetica" , sans-serif;"><br /></span><span style="font-family: "arial" , "helvetica" , sans-serif;">What I found instead was that even though the insurer had sent detailed questionnaires to the three treating physicians, none of the questionnaires asked about the frequency, duration or intensity of the headaches suffered by my client! Why didn’t the insurer ask for the frequency, duration and intensity information that it claimed was crucial to establishing disability? Do you think that the insurance company didn’t want to get the right information from the doctors, and deliberately asked for the wrong information so it could deny benefits? </span></span><br />
<span style="font-family: "arial" , "helvetica" , sans-serif;"><span style="font-family: "arial" , "helvetica" , sans-serif;"><br /></span><span style="font-family: "arial" , "helvetica" , sans-serif;">I will be able to help this migraine disability client. I have ways to establish frequency, duration and intensity, and to prove that the migraines prevent the person from performing their job. Also, since most of my ERISA appeal practice is in in Connecticut and Westchester County, I have worked with her doctors before, so I know we can work together to prove the client’s disability from migraines. This is an example of two things to remember when choosing a LTD appeal lawyer for any type of condition:</span></span><br />
<span style="font-family: "arial" , "helvetica" , sans-serif;"><span style="font-family: "arial" , "helvetica" , sans-serif;"><br /></span><span style="font-family: "arial" , "helvetica" , sans-serif;">•<span style="white-space: pre;"> </span>Choose a lawyer who has substantial of experience with ERISA LTD appeals so he or she knows how to prove disability with your particular condition; and</span></span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">•<span style="white-space: pre;"> </span>Choose a local lawyer who may have dealt with your doctors before. Knowing how a specific doctor works, what they want to see from the lawyer, and how responsive they are quite helpful in winning an ERISA LTD appeal. </span>David S. Rintoulhttp://www.blogger.com/profile/14474646582143975303noreply@blogger.com0tag:blogger.com,1999:blog-4803692353238609944.post-85640936830636239702016-10-25T06:29:00.001-07:002016-10-25T06:32:38.792-07:00Proving Disability in Internal ERISA Benefit Appeals: Why It Is Easy to Get it Wrong<span style="font-family: "arial" , "helvetica" , sans-serif;">In my ERISA benefits practice, I often have the opportunity to review the work other lawyers have done in the initial internal appeal with the insurance company. </span><span style="font-family: "arial" , "helvetica" , sans-serif;">For more background on why the internal appeal process is so important, you can see </span><a href="http://www.znclaw.com/appealing-ltd-denials.html" style="font-family: Arial, Helvetica, sans-serif;">this article</a><span style="font-family: "arial" , "helvetica" , sans-serif;"> from my firm’s website. </span><span style="font-family: "arial" , "helvetica" , sans-serif;">Most often, the lawyers have not done many ERISA internal appeals. They may think that long-term disability appeals are not really that different from other areas where inability to do a job is an issue, such as a Social Security Disability Income denial or workers’ compensation. </span><span style="font-family: "arial" , "helvetica" , sans-serif;"> </span><span style="font-family: "arial" , "helvetica" , sans-serif;"> </span><br />
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<li><span style="font-family: "arial" , "helvetica" , sans-serif;">In one way, they are right: in each area, the claimant must show he or she can’t work, so the burden of proof is on the claimant.</span></li>
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<span style="font-family: "arial" , "helvetica" , sans-serif;">BUT</span><br />
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<li><span style="font-family: "arial" , "helvetica" , sans-serif;">What is required to meet the burden of proof in the three areas is fundamentally different. Evidence that can win a workers’ compensation or SSDI case can be a loser in a disability insurance case. </span> </li>
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<span style="font-family: "arial" , "helvetica" , sans-serif;">In both Social Security and workers’ compensation cases, once a claimant submits a certain amount of evidence, the effective burden of proof is shifted: </span><br />
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<li><span style="font-family: "arial" , "helvetica" , sans-serif;">Social security disability income appeals have a “treating physician rule:” once the claimant submits an opinion of disability from a treating physician supported by medical evidence, the claimant generally wins.</span></li>
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<li><span style="font-family: "arial" , "helvetica" , sans-serif;">In workers compensation, a doctor’s statement that contains the magic words “I state with a reasonable degree of medical certainty,” that a disability resulted from a workplace injury may be enough to force the insurance company to prove that the opinion is wrong.</span></li>
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<span style="font-family: "arial" , "helvetica" , sans-serif;">Of course, the doctors’ statements in these areas have to be supported by the medical records, but in many cases the treating doctor’s statement can be short and conclusory.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">Claimants in ERISA cases don’t get the benefit of these presumptions: while a plan has to have some reason to reject a treating physician’s opinion, there is no treating physician rule that requires deference. A short doctor’s letter that can win a workers’ compensation case can probably be safely ignored by an ERISA plan that has a contrary opinion from a doctor who has only reviewed medical records and has not examined the patient. </span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">Two aspects of ERISA make it more difficult to establish disability than under SSDI or workers’ compensation: </span><br />
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<li>Th<span style="font-family: "arial" , "helvetica" , sans-serif;">e first is the basic ERISA principle that the language of the plan documents governs almost everything. To a great degree, the plans get to establish what a claimant must show to be entitled to benefits, and understandably, they do not make it easy.</span></li>
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<li><span style="font-family: "arial" , "helvetica" , sans-serif;">The second is the standard by which a court is likely to review the benefit denial. Due again to language in the plan, almost every benefit denial reviewed by a court is going to be arbitrary and capricious review, which means the court is supposed to uphold the denial if there is any rational basis for the decision. So, what happens when a lawyer submits a doctors’ letter that could win a workers’ compensation case? The court is likely to hold that a plan that relies on a medical file review paid for by the plan rather than a short letter stating the doctor’s opinion has a rational basis for the denial, and the claimant loses. </span></li>
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<span style="font-family: "arial" , "helvetica" , sans-serif;">In many states, it can be hard to find a lawyer who is experienced with appealing long-term disability denials, either for private insurance or group plans governed by ERISA. In Connecticut where I practice, there are only a few experienced long-term disability insurance attorneys. But, finding an attorney who knows how different it is to prove an inability to work in an ERISA case can make the difference between winning and losing.</span><br />
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David S. Rintoulhttp://www.blogger.com/profile/14474646582143975303noreply@blogger.com0tag:blogger.com,1999:blog-4803692353238609944.post-88367028770806318632016-09-13T14:49:00.002-07:002016-09-13T14:50:34.311-07:00What Do We Submit for an Internal Appeal With the Insurance Company?In this blog, I have frequently discussed the importance of the internal appeal with the insurance company. I haven't discussed what we commonly submit for internal appeals, though. I recently posted <a href="http://www.znclaw.com/what-do-we-submit.html">an article</a> to my <a href="http://www.znclaw.com/">new firm's website</a> discussing what I commonly put in the letter, and the reports and medical records I submit with the letter. As you can see, a lot goes into an effective appeal of a long-term disability denial.David S. Rintoulhttp://www.blogger.com/profile/14474646582143975303noreply@blogger.com0tag:blogger.com,1999:blog-4803692353238609944.post-78860860716790054702016-08-29T14:13:00.000-07:002016-08-30T07:18:38.839-07:00In Introduction to Why the Internal Appeal is Important in ERISA Benefit Denials<span style="font-family: "arial" , "helvetica" , sans-serif;">As you may know, I moved my Connecticut LTD and ERISA practice last month to </span><a href="http://www.znclaw.com/" style="font-family: arial, helvetica, sans-serif;">Zeldes, Needle & Cooper</a><span style="font-family: "arial" , "helvetica" , sans-serif;"> in Bridgeport, I've been working on posting articles to the new firm's web site. Today I posted</span><a href="http://www.znclaw.com/appealing-ltd-denials.html" style="font-family: arial, helvetica, sans-serif;"> an article</a><span style="font-family: "arial" , "helvetica" , sans-serif;"> discussing the administrative appeal process and why it is important. It is a good general introduction to the issues involved. As the article notes, the insurance company won't tell you one of the most important things about the internal appeal process: that you probably won't be able to submit any new information in litigation that you haven't submitted during the appeal process. That is why is can be important to have an attorney during the appeal process to make sure you have the best chance to get the result you want in the appeal, and to put you in the best position to win in court if you don't win the internal appeal.</span>David S. Rintoulhttp://www.blogger.com/profile/14474646582143975303noreply@blogger.com0tag:blogger.com,1999:blog-4803692353238609944.post-84114954801756532172016-07-21T06:34:00.000-07:002016-07-21T06:34:15.880-07:00Even Ex-NFL Players Have Trouble Getting Disability Benefits for Post-Concussion Impairments<span style="font-family: Arial, Helvetica, sans-serif;">The New York Times has <a href="http://www.nytimes.com/2016/07/19/sports/football/haruki-nakamura-former-nfl-player-sues-insurer-for-denial-of-claim-related-to-head-trauma.html">an article</a> this week about the lawsuit that Haruki Nakamura brought against Lloyd’s of London for wrongfully denying disability insurance after his doctors, and the NFL, told him he could no longer play in the NFL. While my clients are more likely to sit at a desk and work at a computer all day than tackle an NFL running back, it is remarkable to me in reading the complaint that Mr. Nakamura confronted the same issues as my clients. The post would be far too long if I addressed all the similarities, but I will note a couple of points:</span><br />
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<li><span style="font-family: Arial, Helvetica, sans-serif;">Mr. Nakamura alleges that Lloyd’s imposed “virtually impossible” procedures, making repeated requests for the same documents, losing documents, and distorting medical records. If the procedures were virtually impossible to fulfill for someone who made <a href="http://football.player-salaries.com/players/1265_Haruki_Nakamura">a million dollars a year</a> </span><span style="font-family: Arial, Helvetica, sans-serif;">and had a personal assistant to help deal with the insurance company , imagine how easy it is for an insurance company to impose absolutely impossible requirements on someone who made $75,000 a year and has a working spouse. As I tell my clients, the courts are remarkably tolerant of insurers requiring endless recertification, updated medical records, and independent medical examinations. Even if we think they are grossly unfair, we have to do the best we can to comply, as the insurance company will use any failure to comply as a basis to reject the claim, and we can’t count on a federal judge being sympathetic to the procedural difficulty of complying with the request.</span></li>
<li><span style="font-family: Arial, Helvetica, sans-serif;">The complaint shows how hard it can be to prove post-concussion syndrome and other conditions that result in cognitive impairments. As regular readers of this blog know, I have frequently discussed how it is difficult to get insurers to accept cognitive impairments without a neuropsychological exam. Mr. Nakamura didn’t get such an exam, and it was one basis for the denial. Neuropsych exams are not always a help, though. They are a rough measure that may not show the slight decreases in cognitive ability that can make it impossible to perform a cognitively demanding job like a bond trader, so Mr. Nakamura may have decided not to risk a neuropsych that was not helpful. But, it shows how important it is to have a comprehensive strategy to demonstrate disabling cognitive issues. I always make sure to emphasize and prove any psychological or physical impairments to make up for any difficulties in proving the cognitive side.</span></li>
<li><span style="font-family: Arial, Helvetica, sans-serif;">The case also shows how willing insurers are to ignore the opinions of highly-credentialed treating physicians. Mr. Nakamura’s doctor was “an internationally renowned expert in sports-related concussion” who had established the first and largest research and clinical program on the issue. The doctor on whom the insurer based the denial is employed by “Triangle Forensic Neuropsychiatry,” and has <a href="http://braininjuryexpert.com/manish-fozdar-history-cv/">no particular expertise in concussions</a> </span></li>
<li><span style="font-family: Arial, Helvetica, sans-serif;">Due to the strong medical community in Fairfield County and Southern Connecticut available to support LTD disability appeals, I am fortunate to work with some of the most prominent doctors in their fields. The insurance companies, however, are happy to rely on anyone with the right initials after their name. One insurance company rejected the opinion of a national authority on multiple sclerosis who was a full professor at Yale in favor of an opinion from a family medicine doctor whose only clinical experience was ten years of work in a rural Maine medical clinic. Again, the way to deal with this is a comprehensive strategy to create an overwhelming case for disability.</span></li>
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<span style="font-family: Arial, Helvetica, sans-serif;">The lesson of the Nakamura case is that insurers are equal-opportunity abusers, happy to abuse the rich and famous as well as poor and the middle class. Make sure you are not alone on this journey by finding an experienced, sympathetic and aggressive lawyer who can create the comprehensive strategy necessary to succeed in long term disability appeals and long term disability litigation.</span>David S. Rintoulhttp://www.blogger.com/profile/14474646582143975303noreply@blogger.com0tag:blogger.com,1999:blog-4803692353238609944.post-43031334358514174712015-12-14T08:03:00.000-08:002015-12-14T08:03:05.684-08:00Residential Treatment for Eating Disorders: What Does Your Doctor Need to Say?<span style="font-family: "arial" , "helvetica" , sans-serif;">Slate.com had a great <a href="http://www.slate.com/articles/double_x/cover_story/2015/12/we_need_to_reject_the_false_narratives_around_anorexia.html">article </a>recently by Katy Waldman talking about anorexia, and the potentially damaging narratives that even those in recovery from anorexia tell themselves. As she writes: "[t]</span><span style="color: #281b21; font-family: "arial" , "helvetica" , sans-serif;"><span style="line-height: 19px;">he anorexic impulse to lyricize one’s illness is a prescription for estrangement, for controlling and muffling the messy truths about who we are."</span></span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">In the article, she calls for treatment that addresses the physical issues resulting from eating disorder: nutrition and weight restoration, rather than trying "to crack some psychological code—to unearth the mysterious psychic forces driving the illness</span><span style="font-family: "arial" , "helvetica" , sans-serif;"> " </span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">Whatever type of treatment a patient and his or her doctors want to pursue, obtaining insurance coverage for treatment of anorexia, bulimia and other eating disorders is challenging. As with many issues with ERISA health benefits and group health insurance, what you think should work frequently doesn't.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">In Connecticut, residential treatment of eating disorders, substance abuse and psychiatric illness has been difficult because there were no residential treatment programs for adolescents in the area. There is now residential treatment for adolescents in Fairfield County, at Silver Hill Hospital, which I discussed in a prior <a href="http://ctltdlawyer.blogspot.com/2015/12/residential-treatment-for-eating.html">blog post.</a> But, I believe we will still have many insurance companies denying coverage for residential treatment, even with a local provider.</span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">So, what does your doctor need to say to get coverage for residential treatment of eating disorders, whether it is the "crack the psychological code" treatment or treatment addressed directly to the physical issues of eating disorders that Katy Waldman endorses?</span><br />
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<li><span style="font-family: arial, helvetica, sans-serif;">Typically, a doctor will tell you that:</span></li>
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<span style="font-family: "arial" , "helvetica" , sans-serif;"><b>Residential treatment is the <u>best </u>way for your daughter to recover</b></span></div>
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<span style="font-family: arial, helvetica, sans-serif;">That should do it, right? Nope. </span><br />
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<li><span style="font-family: arial, helvetica, sans-serif;">What if your doctor tells you:</span></li>
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<span style="font-family: arial, helvetica, sans-serif;"><b>Residential treatment is the <u>only </u>way for your daughter to recover</b></span></div>
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<span style="font-family: arial, helvetica, sans-serif;">That's got to do it, doesn't it? The purpose of the policy is to provide treatment to cure problems, so if the treatment is medically necessary for the patient to get better, doesn't the insurance company have to pay for it? </span></div>
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<span style="font-family: arial, helvetica, sans-serif;">Still nope. Under most health insurance policies, to get residential treatment for eating disorders, or for substance abuse treatment, or most any psychiatric illness, the doctor has to tell you:</span></div>
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<span style="font-family: arial, helvetica, sans-serif;"><b>Residential treatment is the only only way to protect your daughter from a serious risk of imminent death or serious injury to herself or others. </b></span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;">I will post more in in the future about what specifically you need to do to make the best case for residential treatment for eating disorders, substance abuse treatment or other psychiatric issues, including the arcane treatment protocols that you have to follow to get benefits. But, reviewing the policy and the incorporated treatment protocols before the claim is submitted will give you the best chance to get insurance coverage for residential treatment of eating disorders in Connecticut or in another state. </span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;">An experienced health benefits attorney can help you get coverage for the treatment that you and your doctors think is best for treatment of eating disorders or other residential treatment. </span></div>
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David S. Rintoulhttp://www.blogger.com/profile/14474646582143975303noreply@blogger.com5tag:blogger.com,1999:blog-4803692353238609944.post-24871856170357127912015-12-07T12:48:00.000-08:002015-12-07T12:48:55.464-08:00Residential Treatment for Eating Disorders Now Available in Connecticut<span style="font-family: "arial" , "helvetica" , sans-serif;">Patients and their parents in Connecticut have frequently encountered great difficultly in obtaining the residential treatment for eating disorders recommended by their doctors. In the past, residential treatment of eating disorders was only available out of state. Insurers fought hard to not cover out-of-state treatment, and I think the expense of out-of-state treatment was one reason for that. I will discuss coverage for eating disorders in a upcoming post, and grounds for appealing a denial of benefits for residential treatment of eating disorders. </span><br />
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<span style="font-family: "arial" , "helvetica" , sans-serif;">Connecticut now has a residential treatment program for eating disorders. </span><span style="font-family: "arial" , "helvetica" , sans-serif;">Silver Hill Hospital in New Canaan </span><a href="http://www.silverhillhospital.org/about-silver-hill/blog/november-2015/silver-hill-hospital-announces-eating-disorders-pr" style="font-family: Arial, Helvetica, sans-serif;">recently started offering residential treatment</a>.<span style="font-family: "arial" , "helvetica" , sans-serif;"> I hope with in-state treatment available, it may be a little easier to obtain coverage for residential treatment of eating disorders in Connecticut. It will still be a fight, but maybe we will start a little closer to the goal. </span><br />
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David S. Rintoulhttp://www.blogger.com/profile/14474646582143975303noreply@blogger.com0tag:blogger.com,1999:blog-4803692353238609944.post-8553482733029951422015-11-18T06:20:00.003-08:002015-11-18T06:20:56.575-08:00Deceptive Attending Physician’s Statements: How to Fight the Form<span style="font-family: Arial, Helvetica, sans-serif;">What your treating physicians say about your condition and disabilities is the most important part of the claims process. If you were an insurance company, wouldn’t it be great if it could come up with a way where it is almost impossible for the doctor to find that you are disabled? Well, some insurers have done that with the form that asks the doctor to list your diagnosis, treatment, and you capacity to perform work-related activities like standing, walking, and lifting. Different insurers have different names for the statements: </span><br />
<br />
<ul>
<li><span style="font-family: Arial, Helvetica, sans-serif;">Sun Life and Aetna call it an Attending Physician’s Statement;</span></li>
<li><span style="font-family: Arial, Helvetica, sans-serif;">Cigna calls it a Physician’s Statement of Disability; </span></li>
<li><span style="font-family: Arial, Helvetica, sans-serif;">Sedgwick calls is a Physician’s Certificate for Disability Benefits.</span></li>
</ul>
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<span style="font-family: Arial, Helvetica, sans-serif;">Some forms are fair, and others are intended to keep your doctor from certifying you as disabled so long as you can occasionally sit, stand or walk. </span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;">Here’s a <a href="http://www.pdffiller.com/100121496-23_STD_Attending_Physician_Statement_Formpdf-Fillable-STD-Attending-Physician-Statement-Form-User-Forms?abtest=popup&utm_expid=2952066-174.L5CjjBXNRJOphBnHarD5fQ.1&utm_referrer=https%3A%2F%2Fwww.google.com%2F">link</a> to an unfair form that Aetna uses for some cases. The crucial part of the form is in the middle, asking the doctor to state whether the patient's ability to sit, walk, stand, etcetera, is "Occasional," "Frequent," or "Constant."</span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;">How does this form convert a physician’s certification of disability into a certification of no disability?</span><br />
<br />
<ul>
<li><span style="font-family: Arial, Helvetica, sans-serif;">The form uses broad categories: The most restrictive category available is “Occasional,” for activities the claimant can perform from .5 to 2.5 hours a day. There is no category for “Never.” So, let’s say you doctor thinks you can stand, sit or walk for half an hour each, or a total of 1.5 hours in a day. So he fills in “O” for “Occasionally” for the sit, stand and walk categories. The doctor understandably believes he has certified that you cannot do a sedentary job.</span></li>
</ul>
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<br />
<ul>
<li><span style="font-family: Arial, Helvetica, sans-serif;">The insurer using the top of the broad range: Despite your doctor’s intentions, the insurer can read this form to establish that your doctor believes you can do a sedentary job. “Occasional” is defined in the form as up to 2.5 hours day. So, adding together the maximum hours for the three categories gives a 7.5 hour a day work capacity. The insurer can therefore use this form to conclude that your doctor believes you can perform a sedentary job requiring sitting, standing and walking, even though your doctor thinks you can only do these things for 1.5 hours! </span></li>
</ul>
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<span style="font-family: Arial, Helvetica, sans-serif;">So, what do you do? How can you fight the form? In my Connecticut LTD denial practice:</span><br />
<br />
<ul>
<li><span style="font-family: Arial, Helvetica, sans-serif;">I use my own form if the insurers’ forms are deceptive, breaking down the first category into “Never,” “Less than 5%,” “5-20%” and “20-33%” so that the insurer won’t be able to convert a doctor’s certification of an 1.5 of work capacity into a full day’s work, or</span></li>
</ul>
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<ul>
<li><span style="font-family: Arial, Helvetica, sans-serif;">I have the doctors prepare a narrative discussing more specifically what my client can and can’t do as it relates to the specific job duties of the position at issue, without being locked into the categories the insurer uses on its forms. </span></li>
</ul>
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<span style="font-family: Arial, Helvetica, sans-serif;">Deceptive attending physician’s statement forms are one of the reasons it can be difficult to represent yourself, whether in an appeal of a LTD denial or an initial application for short-term disability or long-term disability. The best way to fight these tactics is to have an experienced long-term disability insurance attorney in your corner who knows the games insurer’s play, and how to fight them. </span><br />
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David S. Rintoulhttp://www.blogger.com/profile/14474646582143975303noreply@blogger.com0tag:blogger.com,1999:blog-4803692353238609944.post-51684203756248293122015-10-26T04:25:00.001-07:002015-10-26T04:28:42.714-07:00The Disability Insurer Is Calling You a Liar: Objective Evidence of Subjective Conditions<span style="font-family: Arial, Helvetica, sans-serif;">The most common reason stated by insurance companies for denying my clients benefits is there is no objective evidence of the client's impairments. By this they mean that there are no medical or vocational test results assessing the extent the client's impairments affect her ability to work.</span><br />
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Of course, the medical records commonly include many statements by the claimant about her pain, cognitive difficulties, trouble walking, sitting for extended periods, or using a keyboard. The insurers' hardly ever give any weight to these statements, claiming that they are mere subjective complaints; that is, they are not in themselves proof that the person is experiencing what she says she is experiencing. The insurers are in essence calling the patients liars: the insurer clams the patient is telling untrue things to their doctors. This happens frequently with chronic back pain, migraine headaches, fatigue, and early stage Parkinson's and multiple sclerosis. </span><br />
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Why would a patient lie to her doctor? The insurers never say, but there are only two possibilities: </span><br />
<ul>
<li><span style="font-family: Arial, Helvetica, sans-serif;">the patients are suffering from a delusion, that they are not really experiencing the symptoms they are feeling, that the condition is a "somatic disorder" or "psychosomatic disorder"," which is what medical records say then a doctor believes the reported symptoms are the product of a delusion rather than an organic illness; or </span></li>
</ul>
<ul>
<li><span style="font-family: Arial, Helvetica, sans-serif;">the patients are lying in order to qualify for disability benefits, making up symptoms they are not real experiencing. In the medical literature, lying about symptoms to get a financial benefit is called reporting symptoms for "secondary gain."</span></li>
</ul>
<span style="font-family: Arial, Helvetica, sans-serif;">Discounting self-report of pain is fine if there is evidence that the claimant is lying or delusional, such as surveillance in the record, or activities reported in the medical records, that are inconsistent with the limitations the patient is claiming, or the patient claims to have cancer but no cancer can be detected. </span><br />
<span style="font-family: Arial, Helvetica, sans-serif;"><br />
But in the absence of evidence of lying or a mental illness, why should insurers be allowed to call claimants liars just because a medical test doesn't show their chronic pain or cognitive impairment? When objective evidence can't exist, courts in the past decade have done a pretty good job not allowing insurers to deny benefits based solely the fact the impairment is based on subjective complaints. <span style="color: blue;"><a href="https://advance.lexis.com/api/document/collection/cases/id/54J3-KG31-F04D-W1CS-00000-00?context=1000516">Kelly
v. Reliance Std. Life Ins. Co., 2011 U.S. Dist. LEXIS 147133, 2011 WL 6756932
(D.N.J. Dec. 21, 2011)</a> </span>("<span style="background-color: white;">The defendants are not free to ignore the plaintiff's
chronic and severe pain under the apparent theory that MRIs or EMGs must
demonstrate some structural deformity for a person to be disabled because of
back pain. Unfortunately for all parties involved, back pain, even severe
pain, is not so simple.")</span></span><br />
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<!--StartFragment--><!--EndFragment-->But, courts have rarely directly addressed the issue that insurers are really calling claimants liars when the insurers don't credit subjective reports of pain. Remember the context in which these statements are made: in a doctor's office, where the patient is seeking diagnosis and treatment for serious conditions. A patient who lies in a medical office risks painful, dangerous and expensive treatments to address an imaginary malady. And frequently, the patient reported the pain at a time when there is no motivation to lie: the statements may have been made before any application for disability benefits is filed; or when benefits are being paid routinely and the the claimant would have no reason to think their benefits were at risk. </span><br />
<span style="font-family: Arial, Helvetica, sans-serif;"><br />
The rules that govern what evidence can be presented in Federal Court even acknowledge that statements made to a medical professional for purposes of diagnosis and treatment have "intrinsic indicia of reliability," which is judge talk meaning that the statements are likely enough to be true that they should be admitted into evidence. Therefore, statements made to obtain medical treatment are an exception to the hearsay rule that out-of-court statements cannot be admitted into evidence to show that what was said was true. Some courts have accepted this analogy. <a href="https://advance.lexis.com/api/document/collection/cases/id/43B9-6Y20-0038-Y33C-00000-00?page=640&reporter=1109&context=1000516">Lasser
v. Reliance Std. Life Ins. Co., 146 F. Supp. 2d 619, 640 (D.N.J. 2001)</a> (“it was in Dr. Lasser's interests accurately to inform
him of his daily activities in order to obtain an effective program of
rehabilitation. Indeed, it is based on this indicium of reliability that such
out-of-court statements by Dr. Lasser would be admissible under the Federal
Rules of Evidence.”).</span><br />
<span style="font-family: Arial, Helvetica, sans-serif;"><br />
<span style="font-size: small;">In my Connecticut disability insurance practice, I will keep arguing that an insurer can't dismiss a claimant's pain unless there is a factual basis for it. </span><span style="font-size: small;">The insurance company's insist on objective evidence of pain; courts should start requiring long-term disability insurers to produce "objective evidence" that the patient is lying or delusional before calling the claimant a liar. We'll see if Connecticut federal courts will start turning the tables and require insurers to show "objective evidence" that the claimant is not telling the truth in reviewing decisions on long-term disability insurance appeals. </span></span><br />
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David S. Rintoulhttp://www.blogger.com/profile/14474646582143975303noreply@blogger.com0tag:blogger.com,1999:blog-4803692353238609944.post-38441146574733029552015-09-15T08:16:00.000-07:002015-09-15T08:16:00.177-07:00What is ERISA: Retirement Benefits & Fiduciary Duties<div class="MsoNormal">
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<span style="font-family: Arial, Helvetica, sans-serif;">ERISA was enacted primarily to regulate something that we
would all like to have, but hardly exists anymore: the private-sector
traditional pension plan.</span><span style="font-family: Arial, Helvetica, sans-serif;"> </span><span style="font-family: Arial, Helvetica, sans-serif;">These plans
promise retirees a certain payment every month for the rest of their life, and
sometimes a reduced for the life of a spouse.</span><span style="font-family: Arial, Helvetica, sans-serif;">
</span><span style="font-family: Arial, Helvetica, sans-serif;">These are called “defined benefit plans” under ERISA, since the plan
promises to pay definite amount every month.</span><span style="font-family: Arial, Helvetica, sans-serif;">
</span><span style="font-family: Arial, Helvetica, sans-serif;">No matter what happens with the market, the amount you get doesn’t
change.</span><span style="font-family: Arial, Helvetica, sans-serif;"> </span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;">In the other type of retirement plan, the plan promises that
a certain amount of money will go into the plan each year, and the amount you
get each month when you retire depends on what happens with the stock
market.<span style="mso-spacerun: yes;"> </span>These are called “defined
contribution plans.”<span style="mso-spacerun: yes;"> </span>These are the 401k
plans and cash balance plans that most of us have now.<span style="mso-spacerun: yes;"> </span>In the defined benefit plan, the risk of
market changes rests with the employer.<span style="mso-spacerun: yes;">
</span>With the defined contribution plan, the risk of market changes rests on
the retiree.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;">As discussed in my <a href="http://ctltdlawyer.blogspot.com/2015/07/what-is-erisa-what-difference-does-it.html">first post</a> in the “What is ERISA?” series
of post, the primary purpose of ERISA was to protect the traditional defined
benefit pension plan. Most employers have moved to defined contribution plan,
ERISA applies to these plans, too.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;">In the <a href="http://ctltdlawyer.blogspot.com/2015/07/what-is-erisa-welfare-benefits.html">prior post</a> on ERISA and welfare benefits, I discussed
some of the differences between the way ERISA treats welfare benefits versus
retirement benefits: retirement benefits are vested prior to you actually
receiving the benefit; and ERISA imposes substantive requirements on retirement
plans while imposing few on welfare benefit plans.<o:p></o:p></span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;">The most significant effect of ERISA on retirement plans is
that it imposes fiduciary duties on the people who administer retirement
plans.<span style="mso-spacerun: yes;"> </span>A fiduciary duty means that
someone has the obligation to act in another’s interest, rather than his or her
own interest.<span style="mso-spacerun: yes;"> </span>So, a plan fiduciary
responsible for investing the plans assets is supposed to seek the best/safest
return possible, rather than investing in the hot new club opening down the
block.<span style="mso-spacerun: yes;"> </span>Huge treatises have been written
on the scope of fiduciary duties, but below are some examples of cases involving
fiduciary duties under ERISA: <o:p></o:p></span></div>
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<li><span style="font-family: Arial, Helvetica, sans-serif;">Nationwide Life Insurance administers 401k plans for small
and medium-sized companies, and chooses the investment options to be offered to
the plan participants.</span><span style="font-family: Arial, Helvetica, sans-serif;"> </span><span style="font-family: Arial, Helvetica, sans-serif;">The companies
that it managed the plans for sued Nationwide for allegedly choosing mutual
fund companies based on what the mutual fund companies paid Nationwide, rather
than choosing the companies that offered the best investment options at the
lowest cost.</span><span style="font-family: Arial, Helvetica, sans-serif;"> </span><span style="font-family: Arial, Helvetica, sans-serif;">Such an action, acting in
its own interest rather than the interests of those it owed fiduciary duties
to, would violate ERISA’s fiduciary duties.</span><span style="font-family: Arial, Helvetica, sans-serif;">
</span><span style="font-family: Arial, Helvetica, sans-serif;">Northwestern settled the case for $140 million, a record
settlement.</span><span style="font-family: Arial, Helvetica, sans-serif;"> </span><span style="font-family: Arial, Helvetica, sans-serif;"> </span></li>
</ul>
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<ul>
<li><span style="font-family: Arial, Helvetica, sans-serif;">In </span><u style="font-family: Arial, Helvetica, sans-serif;">Amara v. Cigna</u><span style="font-family: Arial, Helvetica, sans-serif;">, a Connecticut ERISA litigation matter,that has
already gone to the U.S. Supreme Court once, and is likely to go again, CIGNA
was sued for telling plan participants that the change from a defined benefit
plan to a defined contribution plan would have no effect on benefits, and that
it was not being done to save money.</span><span style="font-family: Arial, Helvetica, sans-serif;"> </span><span style="font-family: Arial, Helvetica, sans-serif;">In
fact, the benefits were worse for many participants, particularly those
eligible for early retirement, and there were internal emails stating that the
change was intended to save CIGNA money.</span><span style="font-family: Arial, Helvetica, sans-serif;">
</span><span style="font-family: Arial, Helvetica, sans-serif;"> </span><span style="font-family: Arial, Helvetica, sans-serif;">One of the most notable things
about this case is that even though the plan fiduciary was flat out lying to
the participants, courts have struggled to come up for a remedy.</span><span style="font-family: Arial, Helvetica, sans-serif;"> </span><span style="font-family: Arial, Helvetica, sans-serif;">As I have discussed in other posts,
the courts have severely limited the remedies available under ERISA.</span><span style="font-family: Arial, Helvetica, sans-serif;"> </span><span style="font-family: Arial, Helvetica, sans-serif;">That is may take two trips to the Supreme
Court to figure out how to fix this wrong shows how messed up the ERISA
remedial scheme is.</span><span style="font-family: Arial, Helvetica, sans-serif;"> </span><span style="font-family: Arial, Helvetica, sans-serif;">Some courts are
making baby steps towards removing the shackles on ERISA remedies (see this
<a href="http://ctltdlawyer.blogspot.com/2015/01/another-small-indication-courts-may.html">post</a> and this <a href="http://ctltdlawyer.blogspot.com/2014/10/a-court-finally-awards-full-damages-in.html">one</a>), and the </span><u style="font-family: Arial, Helvetica, sans-serif;">Amara</u><span style="font-family: Arial, Helvetica, sans-serif;"> case may be the case that ultimately
unchains ERISA’s remedies.</span></li>
</ul>
<ul>
<li><span style="font-family: Arial, Helvetica, sans-serif;">How plan fiduciaries invest plan assets has been fertile
grounds for ERISA fiduciary litigation.</span><span style="font-family: Arial, Helvetica, sans-serif;">
</span><span style="font-family: Arial, Helvetica, sans-serif;">After the 2008 stock market crash, many cases, called “stock drop
cases,” were brought against plans that invested in the employer’s stock.</span><span style="font-family: Arial, Helvetica, sans-serif;"> </span><span style="font-family: Arial, Helvetica, sans-serif;">While few of the cases succeeded, they
generated a lot of law about the scope of an ERISA fiduciary’s duties in investing
plan assets.</span><span style="font-family: Arial, Helvetica, sans-serif;"> </span><span style="font-family: Arial, Helvetica, sans-serif;">See, for instance, the U.S.
Supreme Court case </span><u style="font-family: Arial, Helvetica, sans-serif;">Fifth Third Bancorp v. Dudenhoeffer</u><span style="font-family: Arial, Helvetica, sans-serif;">, 134 S. Ct. 2459
(2014). This case is an example of why ERISA drives lawyers nuts.</span><span style="font-family: Arial, Helvetica, sans-serif;"> </span><span style="font-family: Arial, Helvetica, sans-serif;">The one line summary of the case is
pro-plaintiff, as the Court rejected a defense commonly used by plan fiduciaries in these
cases. </span><span style="font-family: Arial, Helvetica, sans-serif;"> </span><span style="font-family: Arial, Helvetica, sans-serif;">In the body of the case, though,
the Court sets for rules for what a plaintiff must prove to win that are so
difficult that few plaintiffs will be able to satisfy them.</span><span style="font-family: Arial, Helvetica, sans-serif;"> </span><span style="font-family: Arial, Helvetica, sans-serif;">Little is simple with ERISA litigation.</span></li>
</ul>
<br />
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<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: .25in; mso-add-space: auto;">
<span style="font-family: Arial, Helvetica, sans-serif;">ERISA fiduciary duties have a significant impact on retirement plans, but
the duties also apply to welfare benefit plans.<span style="mso-spacerun: yes;">
</span>For instance, in <u>Devine v. Combustion Engineering</u>, a case where I
was counsel for plaintiffs in a nationwide class action, we alleged Combustion
Engineering had breached its fiduciary duty to the participants by promising
lifetime free health benefits in connection with an early retirement programs,
and then reducing the benefits after they had retired.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
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<br /></div>
<div class="MsoListParagraphCxSpMiddle" style="margin-left: .25in; mso-add-space: auto;">
<span style="font-family: Arial, Helvetica, sans-serif;">The distinction between retirement benefits and non-retirement benefit
under ERISA is one of the arcane distinctions that scare away many attorneys
from practicing ERISA law.<span style="mso-spacerun: yes;"> </span>If you choose
to have a lawyer represent you in these matters, make sure he or she is
comfortable with this and the other arcane aspects of ERISA.<span style="mso-spacerun: yes;"> </span></span><o:p></o:p></div>
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David S. Rintoulhttp://www.blogger.com/profile/14474646582143975303noreply@blogger.com0tag:blogger.com,1999:blog-4803692353238609944.post-76573500290734866052015-09-11T05:37:00.000-07:002015-09-11T05:52:13.470-07:00Plans for the Blog in Coming Months, And What I Did This Summer<div class="MsoNormal">
<span style="font-family: Arial, Helvetica, sans-serif;">If you are a regular reader of this blog (and I hope there
are some!), you may have noticed that nothing new has been posted for a while.<span style="mso-spacerun: yes;"> </span>I’ve had a busy summer, as I got married, and
went for a great honeymoon in Scotland.<span style="mso-spacerun: yes;">
</span>I’ve posted a few pictures below.<span style="mso-spacerun: yes;">
</span>But, probably like you, now that Labor Day is passed, I am excited to
pick up some of the projects that were put aside for the summer.<span style="mso-spacerun: yes;"> </span>Here’s what up for the blog in the coming
weeks:<o:p></o:p></span></div>
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<br />
<ul>
<li><span style="font-family: Arial, Helvetica, sans-serif;">The last part of my series on “What is ERISA,”
discussing ERISA and retirement benefits;</span></li>
<li><span style="font-family: Arial, Helvetica, sans-serif;">A post titled “The Insurance Company’s Calling
You a Liar,” discussing how insurers claim that they can ignore what you say to
the doctor about your pain and impairments, dismissing it as “only self-report.”</span><span style="mso-spacerun: yes;"> </span><span style="font-family: Arial, Helvetica, sans-serif;">Do the insurers really believe that patients
lie to the doctors, the ones on whom they rely for treatment and healing?</span></li>
<li><span style="font-family: Arial, Helvetica, sans-serif;">An update on when a plan can impose a shorter
period for filing a lawsuit than what the law otherwise provides, discussing </span><u style="font-family: Arial, Helvetica, sans-serif;">Mirza
v. Insurance Administrator of America, Inc.</u></li>
<li><span style="mso-ascii-font-family: Cambria; mso-bidi-font-family: Cambria; mso-fareast-font-family: Cambria; mso-hansi-font-family: Cambria;"><span style="mso-list: Ignore;"><span style="font-size: 7pt;"> </span></span></span><span style="font-family: Arial, Helvetica, sans-serif;">I’ll discuss </span><u style="font-family: Arial, Helvetica, sans-serif;">Shaw v. AT&T Umbrella
Benefit Plan No. 1</u><span style="font-family: Arial, Helvetica, sans-serif;">, which shows that courts are increasingly skeptical
about insurers ignoring the opinions of treating physicians unless they have a
sound basis for doing so.</span></li>
</ul>
</div>
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<div class="MsoNormal">
<span style="font-family: Arial, Helvetica, sans-serif;">Let me know what you would like me to discuss in my blog.<o:p></o:p></span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;">And, as promised, here are some pictures of my wedding and
honeymoon in Scotland.</span><o:p></o:p></div>
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David S. Rintoulhttp://www.blogger.com/profile/14474646582143975303noreply@blogger.com0tag:blogger.com,1999:blog-4803692353238609944.post-5406148570383975702015-07-17T06:10:00.000-07:002015-09-09T14:02:50.103-07:00What Is ERISA? Welfare Benefits: Disability Benefits; Health Insurance; Severance Claims<span style="font-family: Arial, Helvetica, sans-serif;">As discussed in the prior post, ERISA governs almost all employee benefits, including non-pension benefits like LTD benefits, severance, and medical insurance. These non-pension benefits were included in ERISA as an afterthought, and not many provisions of the law itself addresses them. Over the forty years ERISA has been in effect, however, the courts have developed a complicated structure to apply ERISA to non-retirement benefits, a structure which the courts regularly change. This is another one of the areas that makes ERISA complex.</span><br />
<span style="font-family: Arial, Helvetica, sans-serif;"><br /></span>
<span style="font-family: Arial, Helvetica, sans-serif;">With a Connecticut LTD denial, an attorney has many options in suing in court or pursuing a remedy with the Connecticut Department of Insurance. With an ERISA LTD case, or other ERISA benefit claim, there are a different set of rules. </span><br />
<span style="font-family: Arial, Helvetica, sans-serif;"><br /></span>
<br />
<ul>
<li><span style="font-family: Arial, Helvetica, sans-serif;">ERISA does not require that a company offer any particular benefits, or require that any particular class of employees be covered. So, a company doesn’t have to offer severance benefits, and can decide that some employees (for instance, part-time employees) are not entitled to benefits. As with everything with ERISA, there are exceptions to this, particularly regarding health insurance after Obamacare, and limitations on favoring highly compensated employees. But generally, employers get to offer what they want to, and they don’t have to fair about it.</span></li>
</ul>
<ul>
<li><span style="font-family: Arial, Helvetica, sans-serif;">Welfare benefits, as opposed to pension benefits, don’t vest. That means until an employee earns the right to get a particular benefit, the employer can change or eliminate the benefit. Pension benefits, on the other hand, cannot be changed once the benefits vest, even if the employee is not yet receiving pension payments. So, the day before you are laid off, the employer can eliminate a severance plan, and there is nothing you can do about it. As with everything with ERISA, there are exceptions: once you have started to receive benefits, the employer can’t take them away.</span></li>
</ul>
<ul>
<li><span style="font-family: Arial, Helvetica, sans-serif;">Prior to going to court to get benefits, you must exhaust any appeal rights that exist with the plan. Nothing in ERISA requires this appeal, but the courts require it in almost every case. So, after the plan denies your severance claim, health insurance claim, LTD claim or other welfare benefit, you must write the employer and ask them to change its mind. Once the courts imposed the requirement, the Department of Labor issued regulations requiring plans to provide a fair and unbiased review of the denial. Anyone who has been following this blog knows how important the administrative appeal is. Even though it is not required by ERISA itself, it is one of the most important things in getting benefits that have been denied. It is an example of the dangers ERISA presents to inexperienced lawyers.</span></li>
</ul>
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<span style="font-family: Arial, Helvetica, sans-serif;"><br /></span>
<span style="font-family: Arial, Helvetica, sans-serif;">Regarding health insurance, the Affordable Care Act, or Obamacare, has changed the landscape for denied medical benefit claims in many cases. See my post on this <a href="http://ctltdlawyer.blogspot.com/2014/10/denied-health-benefits-under-erisa.html">here</a>, and my post on the Supreme Court’s decision in <u>King v. Burwell</u> upholding key provisions of the act <a href="http://ctltdlawyer.blogspot.com/2015/06/supreme-court-comes-through-with.html">here</a>.</span><br />
<span style="font-family: Arial, Helvetica, sans-serif;"><br /></span>
<span style="font-family: Arial, Helvetica, sans-serif;">Despite the changes made by Obamacare, plan participants in Connecticut and elsewhere with medical benefit claims, long and short disability benefit claims and severance claims, will have to go through the ERISA maze to vindicate their rights to benefits. Make sure you have a guide in the maze who has been there before.</span><br />
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David S. Rintoulhttp://www.blogger.com/profile/14474646582143975303noreply@blogger.com1tag:blogger.com,1999:blog-4803692353238609944.post-16369486813098336732015-07-13T09:53:00.000-07:002015-07-13T09:53:25.312-07:00What is ERISA? What Difference Does it Make?<span style="font-family: Arial, Helvetica, sans-serif;">Even if you are new to the world of employee benefits, you have probably regularly seen references to ERISA, but you may not have run across an explanation of what it is. In this post, I’ll discuss what ERISA is, and what tyipically are the most important consequences of a benefit issues being an ERISA case as opposed to a non-ERISA case. </span><br />
<span style="font-family: Arial, Helvetica, sans-serif;"><br /></span>
<span style="font-family: Arial, Helvetica, sans-serif;">ERISA is the acronym for the Employee Retirement and Income Security Act, which is a federal law enacted in 1974. The law was mainly intended to protect employee pensions. Companies were going bankrupt without fully funded plans. For instance, when Studebaker closed in 1963, its workers received 15% of the pension they had been promised. Also, employees had to work a long time to vest in a pension, even as much as ten years, and the employee would get nothing if he missed the vesting date by a day. Employers therefore had a strong incentive to fire employees shortly before their pensions vested. ERISA addressed these issues by requiring full funding of retirement plans and less onerous vesting schedules, and by protecting employees from being fired because the employee was about to earn a pension. ERISA imposes fiduciary duties on those who administer the plan and invest plan assets to act in the interests of the beneficiaries rather than the employer. </span><br />
<span style="font-family: Arial, Helvetica, sans-serif;"><br /></span>
<span style="font-family: Arial, Helvetica, sans-serif;">In addition to pensions, ERISA covers non-pension employee benefits, called “welfare benefits” in the Act. In future posts, I’ll discuss the effect of ERISA on pension claims, and on welfare benefits claims. In the remainder of this post, I’ll talk about some of the principles of ERISA that apply to both types of claims.</span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;">Only plans established by private employers are subject to ERISA. Plans for federal, state or local government employees and plans established by churches and other religious institutions are not subject to ERISA. Also, benefits that you buy yourself, like a private disability policy, are not governed by ERISA. </span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;"><b>What’s Special About ERISA?</b></span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;">The ERISA laws passed by Congress establish a relatively simple legal foundation, though with technical requirements that can cause problems for an inexperienced lawyer. In addition to the law Congress passed, the courts have developed an elaborate structure on the statutory foundation that is arcane and technical, and changes every few years. I’ll state the general principles, but there are technical exceptions to almost everything I will say here, so don’t think these principles apply in all cases.</span><br />
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<li><span style="font-family: Arial, Helvetica, sans-serif;">Federal law governs any matter covered by ERISA. ERISA preempts all state laws. “Preemption” means that federal law displaces all state laws that deal with the subjects ERISA addresses. For instance, in a Connecticut denial of LTD benefits not subject to ERISA, I might be able to recover for an unfair insurance practices claim, and get punitive damages and emotional distress damages, and a jury would hear the claims. If the plan is governed by ERISA, then I won’t be able to bring any of these causes of action, I will be in federal court, not state court, and I won’t get a jury. </span></li>
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<li><span style="font-family: Arial, Helvetica, sans-serif;">Because no state laws apply to claims, limited damages can be recovered. Basically, if you win under ERISA, all you are going to get is the benefits the company should have paid you in the first place. You won’t get compensation for the sleepless nights you had wondering how you would pay the mortgage, or whether you would have to ask your daughter to leave college. Maybe, if you win in court, your attorney will get some fees, but that is it. Individual ERISA cases are therefore much less lucrative for attorneys, which means it is much harder to find an attorney to represent you in an ERISA benefit denial.</span></li>
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<li><span style="font-family: Arial, Helvetica, sans-serif;">In ERISA, the official plan documents are all that matter. The official plan documents consist of the plan document itself (frequently the insurance policy in an LTD claim), and the Summary Plan Description, which is a plain language explanation of benefits that is given to the plan participants. Even if the president of the company sends you a letter, countersigned by the chairman of the board of directors, that you will get a certain benefit, if the benefit is not in the plan documents, you probably won’t be able to enforce the promise. Employee benefits departments frequently give out wrong information, but rarely can the employees do anything about it, even if the employee has suffered real damage from depending on the wrong information. That the plan documents control can also be a good thing. If the plan provides that you are entitled to benefits, you must be paid them, even if the employer thinks they are too expensive or that you don’t deserve them. But in general, limiting benefits to what is provided in the plan documents makes ERISA cases more difficult than other cases.</span></li>
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<span style="font-family: Arial, Helvetica, sans-serif;">While the statutes and the cases interpreting them are complex, many of the legal principles are the same as lawyers always deal with: benefits claims are basically breach of contract claims; and breach of fiduciary claims are based on trust law principles that are hundreds of years old. Navigating the complicated course of regular law and ERISA’s special rules is complex, but finding a lawyer experienced in the area can help you get the benefits you have earned, and vindicate the few rights that ERISA gives you, whether you are seeking ERISA pension benefits, severance pay, medical benefit claims, or long term disability.</span><br />
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David S. Rintoulhttp://www.blogger.com/profile/14474646582143975303noreply@blogger.com0tag:blogger.com,1999:blog-4803692353238609944.post-77158886185664570362015-06-25T14:26:00.000-07:002015-07-17T06:09:36.549-07:00Supreme Court Comes Through For Obamacare!<span style="font-family: Arial, Helvetica, sans-serif;">If you are interested enough in the topics I discuss in this blog, you probably already know that the Supreme Court, in the case of <u>King v. Burwell</u>, upheld the health insurance subsidies that are a key part of Obamacare. In my civilian life as a liberal democrat and strong supporter of President Obama, I am happy with the decision.</span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;">But, as a Connecticut ERISA lawyer, I am happy for what the decision means for my clients. For all the problems with insurance that I discuss in this blog, insurance is a good thing, and good insurance is a great thing! Obamacare, or more formally the Affordable Care Act, is achieving its goal of increasing the number of insureds, and making sure that insurance is more likely to cover the expenses from a serious health condition. You may need my help, or another ERISA attorney, to appeal an insurance company's denial of a medical claim. I would rather have that fight, though, then try to keep a hospital from foreclosing on your house for unpaid medical bills. </span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;">The Act does other good things. For years prior to the Act, I had clients who used up their COBRA, or couldn't afford COBRA, and had preexisting medical conditions that prevented them from buying private insurance. Or, once they lost their jobs, they had no way of affording health insurance, but now, they can get subsidies on the health exchanges. </span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;">There are problems with the law, of course. and any program as huge as Obamacare will have problems with implementation. But with the Supreme Court's decision today, the question of the legality of the Act should be over, and opponents and supporters can work together to make the law more effective and fair. </span>David S. Rintoulhttp://www.blogger.com/profile/14474646582143975303noreply@blogger.com0tag:blogger.com,1999:blog-4803692353238609944.post-48676609646307535962015-06-16T18:35:00.002-07:002015-06-18T04:08:23.329-07:002015 ERISA Litigation Review<span style="font-family: Arial, Helvetica, sans-serif;">For the sixth year, I've prepared the annual review of ERISA litigation for the Annual Review of the Labor and Employment Law Section of the Connecticut Bar Association. <a href="http://www.bpslawyers.com/ERISA-Litigation-Update.pdf">Here</a> is a link to the article. It is intended for lawyers, but it can give you an idea of the current state of ERISA litigation. Among the topics discussed are:</span><br />
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<li><span style="font-family: Arial, Helvetica, sans-serif;">What remedies are available under ERISA for both participants and plans;</span></li>
<li><span style="font-family: Arial, Helvetica, sans-serif;">Pending cases in the Supreme Court whether plans have the right to recover from personal injury recoveries for medical claims paid, and whether the Summary Plan Description is a plan document that can be enforced;</span></li>
<li><span style="font-family: Arial, Helvetica, sans-serif;">The latest installment of the saga of <u>Amara v. Cigna</u>, where trial courts, appellate courts and the Supreme Court have striven mightily to try to fashion a remedy when a plan lies to its participants, constrained by the Supreme Court's prior decision severely limiting the remedies of plan participants. </span></li>
<li><span style="font-family: Arial, Helvetica, sans-serif;">Long-term disability litigation in Connecticut district courts and other federal trial courts. Several of the cases found against the insurer on grounds that the company's basis for disregarding the treating physicians opinions were not valid. They provide some good clues about how to attack the insurer's decisions on appeal. </span></li>
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<span style="font-family: Arial, Helvetica, sans-serif;"><a href="http://www.bpslawyers.com/Employment-Law/Employment-Benefits.shtml">Here</a> is a link to my Employee Benefits Practice Page, which has links for the ERISA litigation updates I've prepared for the Connecticut Bar Association for 2010 through 2014. Reading them together gives a good sense of the evolution of ERISA benefit appeals in Connecticut, and throughout the country. </span></div>
David S. Rintoulhttp://www.blogger.com/profile/14474646582143975303noreply@blogger.com0tag:blogger.com,1999:blog-4803692353238609944.post-66485314423269327322015-06-12T08:17:00.000-07:002015-06-12T10:20:33.222-07:00What’s The First Thing to Do When you LTD or other ERISA Claim is Denied? Get the Claim File!<span style="font-family: Arial, Helvetica, sans-serif;">Throughout this blog, I have discussed the claim file in discussing other topics. But, I’ve never stepped back and discussed what it is, what ERISA requires regarding the claim file, and why it is important that you get it. </span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;">I was reminded of this when I was speaking to a lawyer pursuing an appeal of a denial of long-term disability benefits in Fairfield County, Connecticut. He isn’t a Fairfield County ERISA attorney, but he is an accomplished lawyer in all respects. I found out that he was finishing an appeal, but hadn’t requested a copy of the claim file. As I’ll discuss below, the claim file is crucial to any LTD benefit appeal. If this lawyer didn’t know about it, I figured it was important to be explicit about the significance of the claim file on my blog, which is intended for an audience of non-lawyers. </span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;">You have an absolute right to get a copy of your claim file under ERISA if any adverse action is taken regarding your claim, such as a denial. You should do it immediately when you get the denial. The denial letter should advise you of your right to get a copy of the file, and whom you have to write to get it. If it doesn’t, send the request to the person who sent the denial letter. You must request it in writing, but you should follow up by phone a few days after you send the request. I think that sometimes requests for claim files are placed on the corner of a desk, and stay there unless someone follows up. Be careful to review the letter you get back along with the claim file. Some companies will construe a request for a claim file as an appeal. That is a problem, because then time deadlines start running, and you won’t have enough time to get medical records, reports or tests done. If the letter you get back says that you have appealed the denial, make sure you write the insurer that you are not appealing the decision at this point.</span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;">The claim file is the record of the insurance company’s activities about any ERISA benefit claim. As you might expect, it has copies of all correspondence to and from the insurer, the claimant, the claimant’s doctors and other medical providers. It also has all the communications between the insurer and the doctors it hires to review your claim, the deliberations of the insurer’s internal medical reviewers, and any medical providers it hires to conduct an independent medical exam of your claim. It includes the insurer’s internal deliberations, including notes of meetings where your claim was discussed, and internal emails discussing the strategy for reviewing your claim.</span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;">It would be hard in a single blog post to list all the ways the claim file can support your claim, but here are a few of them:</span><br />
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<li><span style="font-family: Arial, Helvetica, sans-serif;">You can find out the name of the doctors who conducted the file reviews and IMEs, so you can determine if they are qualified to give an opinion on the medical condition at issue. You need to know if the insurance company doctor who rejected the opinion of your board-certified rheumatologist on the Yale Medical School faculty with many published articles on fibromyalgia, is a family medicine doctor employed by Unum who last practiced 10 years ago in rural clinics in Maine.</span></li>
<li><span style="font-family: Arial, Helvetica, sans-serif;">Reports obtained by the insurance company may help you. I found one file where the insurance company sent the insured to a functional capacity evaluation that found he couldn’t do the job, and the insurance company disregarded the report. If I hadn’t seen the claim file, I would have never known that.</span></li>
<li><span style="font-family: Arial, Helvetica, sans-serif;">You can find medical records that support you that the company ignored. Even without the claim file, you’ll have access to the record through your doctor. But, it is a good argument to show that the decision was not made in good faith if the insurer is ignoring evidence helpful to you that is in its own file.</span></li>
<li><span style="font-family: Arial, Helvetica, sans-serif;">You can find out what records were given to the doctor who conducted the Independent Medical Exam, or the physician reviewing your medical records. Sometimes they don’t give the entire medical record, culling out materials that would be helpful to you. </span></li>
<li><span style="font-family: Arial, Helvetica, sans-serif;">You may see that the insurer decided to deny the claim even before obtaining any tests or file reviews to justify the decision, which again goes to show that the decision was not made in good faith.</span></li>
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<span style="font-family: Arial, Helvetica, sans-serif;">There are many other ways in which the claim file can be used to mount a successful appeal, and put you in the best shape if you have to go to court on your claim. Get the file first thing, and you, or your ERISA benefits lawyer, can start preparing your appeal without delay. And, if the lawyer handling your LTD benefit appeal hasn't obtained a copy of the claim file, well then . . .</span><br />
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David S. Rintoulhttp://www.blogger.com/profile/14474646582143975303noreply@blogger.com0tag:blogger.com,1999:blog-4803692353238609944.post-2886304075821592762015-06-01T11:32:00.002-07:002015-06-01T11:41:32.064-07:00If You Make the Same Arguments In Your ERISA Appeal that You Made Before, Get Ready To Lose <span style="font-family: Arial, Helvetica, sans-serif;">When you submitted your initial application for long-term disability benefits, or any other benefit subject to ERISA, you thought you submitted enough to show that you were disabled: </span><br />
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<li><span style="font-family: Arial, Helvetica, sans-serif;">Your claimant statement recited the many things you could no longer do at work or at home; </span></li>
<li><span style="font-family: Arial, Helvetica, sans-serif;">Your doctor submitted an Attending Physicians Statement outlining how little you can sit, stand, keyboard, lift, etc.; </span></li>
<li><span style="font-family: Arial, Helvetica, sans-serif;">You bugged your doctors for weeks to get them to produce the medical records requested by the insurance company. </span></li>
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<span style="font-family: Arial, Helvetica, sans-serif;">If your treating physician gave an opinion that you were disabled, how could the insurer disagree?</span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;">So, you are shocked when you get the denial. You immediately start making a list of the evidence the company ignored: the doctor’s opinions rejected for no good reason; the unfair conclusions; your detailed statement about what you could do. You are outraged at the decision, and you want to insurance company know all the ways it messed up. If the company just conducted the “full and fair” review that is mentioned in the denial letter, they can’t help but grant you benefits, right?. So, you prepare an appeal of the denial of long-term disability benefits, pointing out all the things in the materials you submitted that show you are disabled that the company ignored. </span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;">Prepare to be shocked again, because it is almost inevitable that you will be rejected again. Even if you think you have the best case possible, you have to submit <b>new information</b> for the appeal. After all, the appeal will be decided by the same company that denied benefits the first time. The company is not going to change its mind without new evidence, no matter how unreasonable the first denial was. </span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;">ERISA requires that the insurer state the reasons the claim was denied, and what information has to be submitted to prove the disability. Take advantage of one of the provisions of ERISA that actually helps you! Use the denial letter to find out exactly what new information you need to submit to have the best chance to prevail in your appeal. </span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;">The types of information you should submit is addressed elsewhere in this blog: get a neuropsych exam; have a functional capacity evaluation done; have your doctor do a new evaluation of your cervical spine to specifically address the issues raised by the insurance company. The information submitted with the appeal will be different in every case, since it has to address the specific reasons raised by the company for denying the appeal. And, you certainly will point out the errors the insurance company made in its initial decision. But, you will discuss it after you present and argue your new information. </span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;">It is hard not to respond reflexively, </span><span style="font-family: Arial, Helvetica, sans-serif;">to defend what you have done, </span><span style="font-family: Arial, Helvetica, sans-serif;">when you receive an indefensible decision by an ERISA plan or insurer. But, step back, take a breath, and figure out what new information you need to submit to address the grounds for denial set forth in the denial letter. Having an ERISA attorney in Connecticut, or your state, can be a big help in the process in providing the knowledge and experience you need to get the benefits you earned. </span><br />
<br />David S. Rintoulhttp://www.blogger.com/profile/14474646582143975303noreply@blogger.com0tag:blogger.com,1999:blog-4803692353238609944.post-75335300641173064522015-05-25T09:43:00.000-07:002015-05-25T09:43:00.035-07:00Appeal vs. Reconsideration: Don't Get Caught in the Trap!<span style="font-family: Arial, Helvetica, sans-serif;">One of the basic principals of ERISA benefit suits is that prior to filing suit in court, you <b>must</b> file an appeal with the insurer asking for the decision to be reversed. If you don't, your case will be thrown out of court.</span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;">Sometimes, rather than filing an appeal, a claimant, or the attorney, requests that the company "reconsider" the decision, but doesn't use the word "appeal." A request for reconsideration can be useful if you think the insurer overlooked a document, or you can submit a record was missing when the decision was made. Since a reconsideration request is not appeal, you are not using up one of your levels of appeal.</span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;">But, make sure you still file an appeal during the 180 days following the decision even if you have filed a request for reconsideration In the Connecticut LTD denial case of <u>Feher v. Unum Life Ins. Co. of Am.</u>, 2014 U.S. Dist. LEXIS 174536 (D. Conn. Dec. 18, 2014) the attorney for the claimant asked for reconsideration of a benefit denial. After denial of the reconsideration request, the attorney filed suit rather than filing an appeal with the plan. The court dismissed the case for failure to exhaust the appeal rights with the plan, since the request for reconsideration did not count as an appeal. </span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;">This case also shows how important it is to have attorney experienced in ERISA and employee benefits. Without knowing about this specific issue, an attorney would have no reason to know that a request for reconsideration is not the same as an appeal. </span>David S. Rintoulhttp://www.blogger.com/profile/14474646582143975303noreply@blogger.com0tag:blogger.com,1999:blog-4803692353238609944.post-16731250178145329992015-05-20T07:06:00.000-07:002015-05-21T09:44:51.392-07:00Health Insurance Doesn't Always Protect You From Big Bills<span style="font-family: Arial, Helvetica, sans-serif;">The New York Times has <a href="http://www.nytimes.com/2015/05/20/upshot/why-insurance-doesnt-always-prevent-giant-medical-bills.html?hpw&rref=upshot&action=click&pgtype=Homepage&module=well-region&region=bottom-well&WT.nav=bottom-well&abt=0002&abg=0">a post</a> today on people who have health insurance, but are underinsured, defined as paying more than 10% of income towards medical bills. One of the reasons people who are insured still have big medical bills is that the insurance company denies medical claims that they should pay. They deny claims for many reasons, including that the requested treatment is not medically necessary, or is experimental, or the requested treatment is out-of-network and the insurer claims equivalent treatment is available in-network, even though your doctor disagrees. This can occur with both private insurance, and insurance through an employer that is governed by ERISA</span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;">If an insurer does deny on a claim on these basis, you do have remedies that can keep you out of the ranks of the underinsured.:</span><br />
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<li><span style="font-family: Arial, Helvetica, sans-serif;">You can file an appeal with the plan. This is a crucial step. You <b>cannot</b> pursue any of your other remedies until you file the appeal with the plan. Also, it may be your only chance to submit information in support of the appeal. Having an experienced Connecticut ERISA lawyer to handle the administrative appeal can help to make sure you have all the information in the file to succeed at the later appeal levels. </span></li>
<li><span style="font-family: Arial, Helvetica, sans-serif;">For appeals of denied health insurance claims in Connecticut, you can file an appeal with the Connecticut Department of Insurance. . <a href="http://www.ct.gov/cid/lib/cid/EA_ConsumerGuide2009Oct09.pdf">Here</a> is a link to a guide to the process. The Affordable Care Act requires states to establish procedures for appeal of denial health insurance claims, so there should be a similar process in your state if you are not a Connecticut resident. </span></li>
<li><span style="font-family: Arial, Helvetica, sans-serif;">If these don't succeed, you have the option of pursuing your claim in court: in federal court for ERISA claims arising from plans established by your employer; or state court if you purchased the plan directly. Whether you have a good claim in court depends largely how complete your prior appeals were, so be careful with the appeals!</span></li>
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<span style="font-family: Arial, Helvetica, sans-serif;">Insurers do not always pay the claims they should pay under the policy. By effectively appealing the decision, you can increase the chance you will avoid the big bills that will make you underinsured. An experienced employee benefits attorney in Connecticut or your state can be a big help in making this happen.</span></div>
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David S. Rintoulhttp://www.blogger.com/profile/14474646582143975303noreply@blogger.com3tag:blogger.com,1999:blog-4803692353238609944.post-47070678096752939712015-05-01T08:40:00.002-07:002015-06-08T08:29:27.686-07:00Medical Records: For Diagnosis and Treatment or Vocational Assessment?<br />
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<span style="font-family: Arial, Helvetica, sans-serif;"><b>Doctors use medical records for two purposes: for diagnosis and treatment. Insurers use medical records to determine if you can do your job. What’s the problem? </b> </span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;">If you have undergone a denial and an appeal, you have learned that your medical records are the one thing the insurer really looks at in making the disability determination, especially if there is no surveillance or in-person interview. If the insurer doesn't find evidence in the medical records that you can’t do your job, your claim is likely to be denied. </span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;">There are legitimate uses of the medical records by the insurer. Using the medical records to assess the quality of the diagnosis is fine or for direct evidence contradicting a claimed impairment. For instance: </span><br />
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<li><span style="font-family: Arial, Helvetica, sans-serif;">It may be legitimate for the insurer to question a diagnosis of fibromyalgia if the tender points test is not done;</span></li>
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<li><span style="font-family: Arial, Helvetica, sans-serif;">It may be proper for the insurer to consider statements in the medical records that directly disprove a claimed impairment. If inability to twist the neck is a claimed disability, and physical therapy records show full range of movement of the neck, using the records to show there is no neck limitation is legitimate. </span><span style="font-family: Arial, Helvetica, sans-serif;"> </span></li>
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<span style="font-family: Arial, Helvetica, sans-serif;"><b>So what’s the problem?</b></span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;">The problem is that the insurers treat the <i>absence of evidence</i> of vocational impairment as <i>evidence of absence </i>of an impairment: if the medical records don’t say you are impaired, then the insurer will conclude you are not impaired. But, doctors don’t maintain their records to show current vocational impairment. They maintain the records to address two things:</span><br />
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<li><span style="font-family: Arial, Helvetica, sans-serif;"><b>Diagnosis</b>: whether the conditions by which a disorder is diagnosed are present and what testing is necessary to show it; and </span></li>
<li><span style="font-family: Arial, Helvetica, sans-serif;"><b>Treatment</b>: what treatments have been tried, and whether the treatment alleviates the condition and side effects resulting from the treatment. </span></li>
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<span style="font-family: Arial, Helvetica, sans-serif;">If there is something relevant to your ability to work, whether observed by the doctor or that you report to the doctor, but is not relevant to diagnosis or treatment, there is no reason for the doctor to note it in the records. For instance, i</span><span style="font-family: Arial, Helvetica, sans-serif;">f a doctor has treated a patient for years for spinal stenosis, the diagnosis was confirmed years ago by an MRI, and all treatment modalities have been exhausted, the doctor is probably not going to note on the medical records that the patient winced when climbing on the exam table, since that fact will change neither the diagnosis or treatment. The absence of a note of wincing, however, will be interpreted by the insurer showing the patient is not experiencing pain.</span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;">This can happen with any patient who is has a long-term largely stable condition where treatment options have been exhausted, such as back pain, fibromyalgia, traumatic brain injury, carpel or cubital tunnel syndrome, or chronic Lyme disease. But, if the doctor has not noted for two years your reports of pain or his observation of you experiencing pain, the insurer is going to use that absence of evidence as evidence that the impairment is absent. Particularly when paired with ambiguous surveillance, this can be a basis for the insurer to deny benefits that can be hard to attack. </span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;">How do you fight this? As I have repeated many times in the blog, you need to tell the doctor the things you experience that show you cannot do your job, and make sure he notes it in the medical records. Explain to your doctor that the insurance company is going to look to the medical records to assess your ability to work, and make sure he writes down anything that will show you can't do your job. On my website, I have posted <a href="http://www.bpslawyers.com/Articles/Making-Your-Medical-Records-Work-for-You-in-Appealing-Long-Term-Disability-Benefit-Denials.shtml">an article</a> on this issue. </span></div>
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<span style="font-family: Arial, Helvetica, sans-serif;">No doctor went to medical school to fill out insurance company forms. But, I have found that most doctors in Connecticut want to help their patients get disability benefits and win Connecticut LTD appeals. Show respect for their time by offering to pay for their work, and be upfront and ask for what you need. You are likely to get the cooperation you need to succeed in a long-term disability claim or LTD appeal in Connecticut.</span><br />
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David S. Rintoulhttp://www.blogger.com/profile/14474646582143975303noreply@blogger.com0tag:blogger.com,1999:blog-4803692353238609944.post-35807131106957290442015-04-23T06:03:00.002-07:002015-04-23T06:05:37.219-07:00David Was Quoted by the Connecticut Law Tribune Regarding Haddock v. Nationwide Life Insurance<span style="font-family: Arial, Helvetica, sans-serif;">I was quoted in in the Connecticut Law Tribune this week regarding the recent ERISA case of <u>Haddock v. Nationwide Life Insurance Co.</u> in which a class action settlement was approved with a payment of $140 million to class members, and attorneys’ fees of $49,000. The plaintiffs in the case asserted that the company administering their 401k plans based on whether the funds would pay the company fees rather than choosing funds that would have the lowest fees for participants. </span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;">Here is a link to the <a href="http://www.ctlawtribune.com/id=1202724138345/Conn-Judge-OKs-140-Million-Settlement-in-Retirement-Benefits-Case?mcode=1202615402746&curindex=6">article</a> (free registration required). Here’s the part where I was quoted:</span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;"> David Rintoul, of Brown, Paindiris, & Scott's Glastonbury office, was not involved in the case but focuses on ERISA issues and authors an ERISA blog. Rintoul explained that this litigation was not between individual investors and Nationwide; instead, the plaintiffs were the executives who ran the corporate 401(k) plans. For instance, </span><br />
<span style="font-family: Arial, Helvetica, sans-serif;"> he said if X,Y,Z machine shop had a 401(k) plan and arranged with Nationwide to offer it to employees, Nationwide, in choosing the investment product for the employees, chose which mutual fund which offered to share the most revenue.</span><br />
<span style="font-family: Arial, Helvetica, sans-serif;"> "So it's essentially a kickback," said Rintoul. "It creates the appearance Nationwide was choosing who would give it the best deal rather than the fiduciary duty of doing what was best for the plans and ultimately the participants."</span><br />
<span style="font-family: Arial, Helvetica, sans-serif;"> Rintoul said the landscape has changed significantly since 2001 when this case began. He said there are more requirements now regarding fee disclosures.</span><br />
<span style="font-family: Arial, Helvetica, sans-serif;"> "To some extent, Nationwide addresses an issue [in the settlement] that shouldn't exist anymore," said Rintoul.</span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;">While this blog is primarily focused on those with long-term disability benefit claims, my ERISA practice covers all areas of ERISA, including breach of fiduciary duty cases. If you have any potentional breach of fiduciary duty cases under ERISA, please call and I would be happy to discuss it. </span><br />
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David S. Rintoulhttp://www.blogger.com/profile/14474646582143975303noreply@blogger.com0tag:blogger.com,1999:blog-4803692353238609944.post-290897800249283812015-03-22T12:17:00.001-07:002015-03-22T12:17:55.471-07:00Request Reasonable Accommodation: Show You Can’t Work, Not That You Don’t Want to<span style="font-family: Arial, Helvetica, sans-serif;">Requesting reasonable accommodation can help get LTD benefits, or win an appeal of a denial of LTD benefits. In my <a href="http://ctltdlawyer.blogspot.com/2015/03/from-diagnosis-to-disability-reasonable.html">prior post</a>, I discussed how exercising your rights under the Americans with Disabilities Act to request reasonable accommodation can help you remain in your job when your medical condition impairs your ability to perform some aspects of your job, but you can still perform the essential functions of your position. In this post, I’ll discuss the effect a request for reasonable accommodation can have on your application for disability insurance benefits under either an ERISA group LTD policy or a private disability policy under Connecticut law.</span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;">Applying for reasonable accommodation when you are still working can help you two ways:</span><br />
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<li><span style="font-family: Arial, Helvetica, sans-serif;">First, under some disability policies, you are not considered disabled if you can so your job with reasonable accommodation. If there is a reasonable accommodation that the insurer believes would allow you to keep doing your job, then you won’t be considered to be disabled. For instance, if the insurer's physician decides you can do your job if you get up and move around every hour, then you won’t be disabled even if you can’t sit all day. If, however, you have tried the reasonable accommodation when you are still working and it didn't work, you will have a basis to refute the insurer’s reasonable accommodation argument.</span></li>
<li><span style="font-family: Arial, Helvetica, sans-serif;">Second, doing everything you can to stay in your job, including requesting reasonable accommodation, shows the insurer that you are only applying for LTD benefits because <b>can’t</b> work, not because you don’t <b>want</b> to work. Insurers are always on the watch for claimants who are interested in “secondary gain,” that is, patients who report impairments to get some other benefit from claiming impairments (such as getting LTD benefits) rather than to receive treatment. You have to be particularly careful of this if your medical records contain statements that you hate your job, it is causing you stress, you don’t like your supervisor, or you want to spend more time with you kids. You don’t want to raise issues about your motivation for applying for benefits.</span></li>
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<span style="font-family: Arial, Helvetica, sans-serif;">As discussed in the prior post, reasonable accommodation can be complicated, and depends very much on your particular impairments and the actual requirements of your particular position. Having an attorney who knows federal and Connecticut employment laws, and who can handle a Connecticut LTD appeal or a LTD suit in the Connecticut district court can be helpful. Whether you use an attorney or not, asking for reasonable accommodation while you are still working can help you qualify as disabled, and will certainly help show that you aren’t applying for benefits simply to avoid working.</span><br />
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David S. Rintoulhttp://www.blogger.com/profile/14474646582143975303noreply@blogger.com0tag:blogger.com,1999:blog-4803692353238609944.post-64340260608400438022015-03-19T12:31:00.000-07:002015-03-19T12:36:00.075-07:00From Diagnosis to Disability: Reasonable Accommodation Can Help Keep You At Work<span style="font-family: Arial, Helvetica, sans-serif;">Reasonable accommodation is a right established by the Americans with Disability Act or “ADA.” The ADA says that an employer cannot discriminate against an employee who is able to perform the essential functions of a position with or without reasonable accommodation. There are enough concepts stuffed into that one phrase that multi-volume treatises can, and have, been written about the meaning of each of the words. This post can only give the most basic introduction to the law of this area, but it will give you some idea of how the reasonable accommodation part of this law can help you keep working.</span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;">The ADA requires employers to eliminate job functions that are not essential functions of the job or modify the way they are performed, so long as the employee can still perform the essential functions of the position. When an accommodation will be considered “reasonable” depends crucially on the particular job. Eliminating a requirement of lifting a boiler might be reasonable if the workplace has several other employees who can do it instead, but it might not be reasonable if the employee works alone. </span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;">Among the types of reasonable accommodations that are helpful to those with cognitive and physical degenerative positions include:</span><br />
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<li><span style="font-family: Arial, Helvetica, sans-serif;">A later start time if medications or a condition make it difficult to get up in the morning;</span></li>
<li><span style="font-family: Arial, Helvetica, sans-serif;">A place to take a nap in the afternoon;</span></li>
<li><span style="font-family: Arial, Helvetica, sans-serif;">Communicating with a supervisor by email if oral instructions are difficult to organize;</span></li>
<li><span style="font-family: Arial, Helvetica, sans-serif;">Work at home, full-time or part-time, which is one of the most useful accommodations, but one of the hardest ones to get;</span></li>
<li><span style="font-family: Arial, Helvetica, sans-serif;">Elimination of travel;</span></li>
<li><span style="font-family: Arial, Helvetica, sans-serif;">No required overtime.</span></li>
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<span style="font-family: Arial, Helvetica, sans-serif;">Many of these can be difficult to get, especially since many employer still don’t realize how much the ADA requires them to do to accommodate disabilities. For instance, an employer in Fairfield County recently refused working from home as a reasonable accommodation because “then everyone will want it then.” Giving something to someone with a disability that everyone else doesn’t get is the essence of a reasonable accommodation under the ADA. Connecticut </span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;">Requesting reasonable accommodation can also put you in a better position when you apply for long-term disability benefits or in appealing a denial of long-term disability benefits. I will discuss the issue in my next post, but make sure you consider the effect on your long-term disability insurance claim or appeal while discussing reasonable accommodation with your employer. </span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;">Having a lawyer to negotiate reasonable accommodation can be useful, as a lawyer can remind employers what they are required to do, and advise you about what is possible under federal and Connecticut state law, especially one who can handle the accommodation request in a way to put you in the best position possible in a Connecticut long-term disability claim or Connecticut long-term disability appeal. This blog will discuss other issues involving the ADA and reasonable accommodation, and their effect on long-term disability insurance claims. Make sure you, and your lawyer, keep it in mind as a way for you to keep working for as long as you want to before you have to apply for disability benefits. </span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;"><u>Other Posts in the Diagnosis to Disability</u></span><br />
<span style="font-family: Arial, Helvetica, sans-serif;"><br /></span><span style="font-family: Arial, Helvetica, sans-serif;"><a href="http://ctltdlawyer.blogspot.com/2014/12/still-working-with-degenerative-disease.html">Diagnosis to LTD Application: Six Things to Consider</a></span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;"><a href="http://ctltdlawyer.blogspot.com/2015/01/working-while-disabled-how-will-it.html">Working While Disabled</a></span><br />
<a href="http://ctltdlawyer.blogspot.com/2014/12/diagnosis-to-ltd-application-when.html"><span style="font-family: Arial, Helvetica, sans-serif;">When Should You Tell Your Employer About Your Chronic Condition?</span></a></div>
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David S. Rintoulhttp://www.blogger.com/profile/14474646582143975303noreply@blogger.com2tag:blogger.com,1999:blog-4803692353238609944.post-27305014212763627282015-03-09T12:56:00.000-07:002015-03-09T12:56:00.152-07:00MS Society Presentation on Managing Cognitive Symptoms and Fatigue in the Workplace<span style="font-family: Arial, Helvetica, sans-serif;">The <a href="http://www.nationalmssociety.org/">National MS Society</a> has a great on <a href="http://www.nationalmssociety.org/getmedia/7e82af59-7ded-4cb8-a65c-fb07f5971aac/Feb-26">presentation</a> on dealing with cognitive deficits, that is, difficulties with thinking, remembering and concentrating, in the work place. The presentation is geared to MS, but would also apply to any degenerative cognitive disease, such as Alzheimer's disease, fronto-temporal lobe disorders, Parkinson's, and side effects of opiods and other medications taken for chronic pain.</span><br />
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<span style="font-family: Arial, Helvetica, sans-serif;">Cognitive deficits from degenerative diseases can present difficulties with long term disability benefit claims. In the early stages, someone may look physically healthy, but have started to suffer cognitive problems. Your boss may doubt that you are disabled if he sees you working out at the gym after you requested a reduced work schedule due to cognitive issues resulting from fatigue. To address the potential doubts, make sure you tell your doctors about the difficulties you are having with cognitive issues. You consider getting a neuropsychological exam to provide a baseline for neurological function so you can prove that your cognitive difficulties have in fact declined. </span>David S. Rintoulhttp://www.blogger.com/profile/14474646582143975303noreply@blogger.com0