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    Question on LTD

    Latest update to my prior posts.
    I was previously denied further LTD benefits after they paid me for 18 months. My first appeal was denied but my second was just recently overturned and they will reinstate my monthly pay but denied my continued group life insurance.
    Two questions for Jamie ( great to see you here! My Dr at Lehigh Valley Neuro mentioned you to me).

    First, do I have grounds to appeal the denial of my life insurance benefit? They indicate the standards are different in regards to levels of disability for my life insurance vs my LTD.

    Second, and most important, my policy indicates I have to bring a lawsuit within 3 years which is coming up in January. My concern is do I need to retain an attorney to file? What is my recourse if they choose to deny my benefits again at some point in the future?

    Thank you!!

    #2
    I will be curious to see Jamie's response.

    I can tell you my experience with the group life. I was no longer eligible once I was no longer an employee. Per the employee benefits, that occurred after 24 months of disability. But prior to that, I was eligible, and company paid the base amount on STD as they would for any employee. For LTD, I could pay the base amount. But for the additional buy up I had, I was not eligible while on LTD. Once my employment was terminated, kicked out of group.

    But for me, all of it was clearly defined in the employee benefits. It stated what eligibility was while on STD and LTD and what would occur after employment terminated.
    Kathy
    DX 01/06, currently on Tysabri

    Comment


      #3
      Kris,

      I'll address your issues separately. First, congratulations on getting the LTD denial reversed. Due to evidentiary issues on these appeals, however, I recommend individuals NEVER file the second appeal without attorney assistance. If you had been denied, an attorney could not have presented any new evidence before the judge if/when a federal suit was brought. Thankfully, you've succeeded in this difficult task, and this is now a moot point in your claim!

      If the insurer denies your disability claim in the future, you would enter right back into the appeals process again. Your recent victory, however, suggests that they are unlikely to challenge your benefits in the near future.

      For the life insurance issue, your next step would be to be to file a federal lawsuit because your in-house appeals are exhausted. Again, these are difficult, due to both the issue with submitting new evidence noted above and because the standard in court is heavily weighed toward the insurer. This is not something that I would consider doing without counsel, and both the medicals on file with the insurer and the language in the insurance policy itself are major considerations.

      Finally, the folks at Lehigh Neurology are great. I've had the pleasure of working with them and their patients since I first opened my own practice. You're free to contact me to discuss the above in further depth.

      -Jamie
      Attorney Jamie R. Hall's practice is focused on assisting individuals with claims and appeals for Social Security Disability and Long Term Disability benefits. He has assisted claimants nationwide, approximately half of whom are MS patients, from his Pennsylvania and Ohio locations. **No attorney/client relationship is created by this communication, and information provided herein is not a substitute for formal advisement.**

      Comment


        #4
        Thank you Jamie.
        I did consult with an attorney in Scranton who didn't feel my case was strong and didn't want to "take my money". I was going to drop it after first appeal and his comments but then decided what do I have to lose?? I was a claims adjuster for 20+ years so I went to every Dr and got all my issues fully documented. My prior choice to suffer in silence with my ailments wasn't helping my case. I also turned in complaint to insurance commissioner due to some comments made by the adjuster and the overall inappropriate handling of my claim.
        I am very happy about them reversing their denial but really upset to lose the security of my life insurance which as you prob can guess, is nearly impossible to get with MS.
        I'll await their letter of explanation and then may call you to further discuss.

        Comment


          #5
          Kris,

          Thank you for the additional information. For the benefit of others who may read this thread, please be careful about what counsel you engage with on long term disability appeals. First, they should do this as a large proportion of their practice; if they are also doing personal injury work, wills, etc., this is not a good sign. Long term disability ("ERISA") litigation is sufficiently unique that a generalist will often lack the skill set and/or time to properly get up to speed on the format.

          Second, the long term disability attorneys I regularly speak with almost exclusively use contingent fee agreements. This means that we only get paid for our work if we are successful, and ensures that we only take cases that will have value for the client.

          -Jamie
          Attorney Jamie R. Hall's practice is focused on assisting individuals with claims and appeals for Social Security Disability and Long Term Disability benefits. He has assisted claimants nationwide, approximately half of whom are MS patients, from his Pennsylvania and Ohio locations. **No attorney/client relationship is created by this communication, and information provided herein is not a substitute for formal advisement.**

          Comment


            #6
            Originally posted by TheMSLawyer View Post
            ... the long term disability attorneys I regularly speak with almost exclusively use contingent fee agreements. This means that we only get paid for our work if we are successful, and ensures that we only take cases that will have value for the client...-Jamie
            Sorry to hijack this thread but this comment raised a question.

            We did as you suggested - reached out to a local attorney who immediately referred us to an attorney to handle LTD appeal (about 3 hours away). After speaking with them my husband was sent a packet outlining what they would do and fees for the services. (Sorry about the confusing us /my husband here, but he cannot read the agreements, and cannot even operate the phone to call out, so I am doing all of the 'leg work')
            In this situation my husband would expect to receive a lump sum (back pay) and and an ongoing monthly payment. From what I understand this attorney would take 50% of lump sum amount plus costs if case was won. If case was not won we would still be responsible for costs.
            Is this a normal agreement?

            BTW this LTD company requires the same standards as SSDI - not able to perform ANY gainful employment. And my husband would be required to file for SSDI.

            Comment


              #7
              I am curious too. In the Philly area, when I called attorneys who specialized in ERISA law (which govern LTD), they were all paid whether win or lose.

              However, the attorney I went with was straight billable hours. They did not take any part of back award. They also tried to minimize bill. They woul give junior attorney and paralegal some of the more time sensitive tasks (getting/organizing medical records, follow up calls, preparing case file) since their billable hours rate was lower, while the attorney did more important key interviews and reviewing file for completeness, preparing final arguments based on contract review, etc...

              Separate attorney for SSDI, which of course, was paid on win only and amount capped by law.

              Both attorneys were specialists in LTD and SSDI respectively.
              Kathy
              DX 01/06, currently on Tysabri

              Comment


                #8
                MSGIJO/Pennstater,

                My office and other offices I am familiar with charge contingent fees for LTD representation. The hourly rate concept is difficult to apply here, as (1) clients generally don't have sufficient excess resources to pay a retainer and (2) the contingent fee ensures that we are all working toward the same goal.

                I've seen the contingent fee designed in several ways. My office uses a fee structure that includes a portion of the lump sum and a much smaller portion of benefits for a limited period of time after the decision. This allows us to follow and assist the claimant post-approval without the need to charge any additional fees. It also allows the claimant to keep a larger portion of the lump sum to catch up on their bills. Absent extraordinary circumstances, we only request costs when a file is approved (I understand that this is not the normal practice, but it seems more fair).

                I lack any knowledge about about the specifics of your husband's case -- which may justify a higher fee -- but I personally have never charged a 50% fee.

                I'd welcome the opportunity to discuss this with you further; you're welcome to send me a direct message with additional questions.

                Best of luck!
                Attorney Jamie R. Hall's practice is focused on assisting individuals with claims and appeals for Social Security Disability and Long Term Disability benefits. He has assisted claimants nationwide, approximately half of whom are MS patients, from his Pennsylvania and Ohio locations. **No attorney/client relationship is created by this communication, and information provided herein is not a substitute for formal advisement.**

                Comment


                  #9
                  Originally posted by TheMSLawyer View Post
                  ... I've seen the contingent fee designed in several ways. My office uses a fee structure that includes a portion of the lump sum and a much smaller portion of benefits for a limited period of time after the decision. This allows us to follow and assist the claimant post-approval without the need to charge any additional fees. It also allows the claimant to keep a larger portion of the lump sum to catch up on their bills. Absent extraordinary circumstances, we only request costs when a file is approved (I understand that this is not the normal practice, but it seems more fair).
                  And that sounds fair to me also.

                  Originally posted by TheMSLawyer View Post
                  ... I lack any knowledge about about the specifics of your husband's case -- which may justify a higher fee -- but I personally have never charged a 50% fee.
                  In my opinion about the only thing that the other attorney had that you don't is a copy of the denial letter which lists the LTD company as Hartford. It also acknowledged that his current limitations were severe and not expected to improve and suggested a few jobs which in their opinion he could do - but they are wrong.

                  My husband has filed for SSDI and we are working that end now. At first denial we have decided to turn it over to the attorney that I used for my SSDI. We are currently pursuing additional tests (cognitive function testing).

                  I may reach out to you at a later point, but right now between MS (me) and taking care of everything and him too it is just too much to chase off in different directions.

                  Thank you for taking the time to answer my questions.

                  Comment


                    #10
                    Msgigo - not sure if you retained that lawyer or not. Just know that there are usually time constraints specified in the LTD contract for filing an appeal. I would hate for you to lose out. If you file your own LTD appeal and it is denied, my understanding is that an appeal to the federal judge level can't introduce new evidence. Maybe Jamie can expand on that.

                    It is all so overwhelming to file and appeal. Hope things work out.
                    Kathy
                    DX 01/06, currently on Tysabri

                    Comment


                      #11
                      No we did not retain that attorney.
                      It IS overwhelming handling all of the paperwork - disabilty insurance on loans, managing all of his doctor appointments and tests, application for SSDI, assorted medical/doctor forms etc, etc...

                      And that is just on his side of things. I am also taking care of my stuff, and all of the household stuff. That is what is causing me to say enough for right now.

                      Yeah I am aware of the time limits on the LTD. but my thought right now is how much is it really worth? I mean they will cut down the amount of SSDI in relation to any LTD he receives, and that will only result in additional paperwork to fill out at least annually .

                      I am just so tired right now. It has been almost a year of having to step up and take on all of the household duties again as well as the addition duties involved in my husband's care. Thank GOD that I have not had a relapse during this (unless that is what is wrong with me now?).

                      The date that I recall was 2 years on filing appeal. We should (hopefully) have received SSDI by then and have results from other testing that I am trying to get set up for him currently. At that time I will make the decision on whether to appeal for LTD or not.
                      I guess that right now I am just gathering information for use at a later date.

                      Again, thanks everyone.

                      Comment


                        #12
                        MSGIGO,

                        I understand how this can all be overwhelming. There is just one item that I want to point out. If you have an in-house appeal left with the insurer, this would normally have a 180-day appeal period (and this time moves faster than you would think). Creating a good record in house is key to permitting successful litigation at federal court. You'll want to review the decision letter and check if any of in-house appeals are left. If not, then you would be going straight to federal court, which involves an entirely different appeal period.

                        I wish you and your husband the best moving forward; take everything one day at a time!
                        Attorney Jamie R. Hall's practice is focused on assisting individuals with claims and appeals for Social Security Disability and Long Term Disability benefits. He has assisted claimants nationwide, approximately half of whom are MS patients, from his Pennsylvania and Ohio locations. **No attorney/client relationship is created by this communication, and information provided herein is not a substitute for formal advisement.**

                        Comment


                          #13
                          Originally posted by TheMSLawyer View Post
                          ...I've seen the contingent fee designed in several ways. My office uses a fee structure that includes a portion of the lump sum and a much smaller portion of benefits for a limited period of time after the decision. This allows us to follow and assist the claimant post-approval without the need to charge any additional fees. It also allows the claimant to keep a larger portion of the lump sum to catch up on their bills. Absent extraordinary circumstances, we only request costs when a file is approved (I understand that this is not the normal practice, but it seems more fair).

                          I lack any knowledge about about the specifics of your husband's case -- which may justify a higher fee -- but I personally have never charged a 50% fee.

                          I'd welcome the opportunity to discuss this with you further; you're welcome to send me a direct message with additional questions.

                          Best of luck!
                          Can you represent somebody living in South Carolina? If so we need to talk.

                          Comment


                            #14
                            Pre-existing condition exclusion

                            I finally got a hold of my company's LTD policy and have a question about the Pre-Existing condition exclusion:

                            This plan will not cover any Disability or Partial Disability:
                            1.) Which is caused or contributed to by, or results from, a Pre-Existing Condition; and
                            2.) which begins in the first 12 months immediatly after your effective date of coverage,unless you received no Treatment of the condition for any three consecutive months after your effective date of coverage

                            "pre existing condition" means a condition resulting from an Ingury or Sickness for which you were diagnosed or received Treatment within three months prior to your effective date of coverage. A Pre-Existing Condition does not include a condition admitted in the application which was not excluded by signed waiver rider.


                            So, if I was diagnosed 9 months before starting my job, and have always been on treatment. Does that "and" save me? Or would MS always be excluded b/c I received medication for it continuously prior to and throughout my employment?
                            Diagnosed 7/11/11
                            On Copaxone 7/11- 12/13
                            On Tecfidera 12/13- current

                            Comment


                              #15
                              I think he "and" does save you, as long as you don't file for 12 months after the coverage effective date. Mine had similar language. If they excluded all pre-existing conditions outright, then many people would not be eligible for LTD.

                              I would look at the definition of coverage effective date to make sure it is your hire date. I've heard of some policies having a twist on coverage effective date.

                              I am sure our helpful attorney will check in soon and respond.

                              Hopefully you don't need the policy and are just making sure you understand the term. Always wise to do.
                              Kathy
                              DX 01/06, currently on Tysabri

                              Comment

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