Standard Insurance Reverses TBI Disability Insurance Claim Denial
Our client – an employee in the security department for a major university – was injured in a horrible motor vehicle crash. Sadly, he suffered a traumatic brain injury (TBI) which resulted in severe left side weakness. He also had a fractured vertebra in his neck that required surgery, as well as optic nerve issues that required surgery and chronic leg spams with pain. He tried to return to work but eventually his injuries and limitations progressed to the point where simple activities like walking became very difficult. Amazingly, when he applied for long term disability (LTD) insurance benefits through the university’s disability insurance company, The Standard, he was denied.
As a reason for the denial, The Standard claimed that the medical records did not show “enough” to prove disability and that the security guard’s doctors refused to talk to the disability insurance company’s claim investigators about his medical conditions, limitations and restrictions.
To fight Standard Insurance, the guard hired the experienced disability insurance lawyers of Tucker & Ludin, P.A.. As part of our claim investigation, Disability Attorney William C. Demas requested Standard’s claim file, which turned out to be several hundred pages of documents. Attorney Demas analyzed the claim file from The Standard, and developed an argument to attack Standard’s claim handling based on the failure of the disability insurance adjuster failing to perform a full and fair review, which is required under the ERISA law that governs group disability plans.
The Standard’s disability claim representative hired a doctor to review the file, but had failed to send a complete set of documents to the paper reviewing doctor. In fact, the medical reviewer actually advised The Standard that the medical records which were sent were incomplete, arranged in a haphazard way, and hard to follow. However, Standard’s disability rep ignored the reviewer’s concerns. In order to complete his report the medical review just guessed at what the missing pages of the medical reports said and then rendered his opinion that our client was not disabled, and Standard relied upon the report to deny the disabilty claim.
Our disability team obtained the complete medical record, and worked with our client’s treating doctors to obtain opinions about his restrictions and limitations. Ultimately, Mr. Demas filed an appeal with nearly 500 pages of evidence and legal argument proving that LTD benefits were owed to our client.
After receipt of the appeal, The Standard reversed their denial, paid thousands of dollars in back benefits. Standard continues to pay monthly LTD benefits to our client.