By | July 8, 2014

Although this recently decided case was not handled by Attorneys Dell & Schaefer Chartered, it can be used an educational tool for those currently on claim or those thinking of making a claim for disability benefits.

The Factual Background

Sylvia R. suffered from Chronic Fatigue Syndrome. Being employed by GAF Materials Corporation she was apparently covered by a Long Term Disability (LTD) Insurance Policy that would provide her with an income should be unable to perform the duties of her occupation. This Policy was with the Reliance Standard Life Insurance Company.

Due to her disabling condition, Sylvia R. was forced to leave work on July 26, 2008. She applied for LTD benefits and her claim was initially paid by Reliance Standard for the period of January 22, 2009 through January 21, 2011. Reliance Standard then denied her claim at that time due to the fact that under the Policy that governed Sylvia R.’s claim after 24 months of benefits the definition of disability changes.

The Definitions of Disability

Often times in most Group Disability Insurance Policies, what it means to be disabled under the policy will often change after a specified time period. In the GAF Materials Corporation LTD policy, this change occurs after 24 months of benefits have been paid.

Initially, in order to qualify for LTD benefits, one must prove with medical documentation that he or she is unable “to perform the material duties of her regular occupation.” Thus, if the person is a laborer, then the person will satisfy this definition of disability if the medical records prove that he or she cannot perform the material duties of a laborer. In the case of Sylvia R., Reliance Standard agreed that she could not perform the material duties of her regular occupation.

Unfortunately for Sylvia R., and unfortunately for most disability claimants, after benefits are paid for 24 months, the definition of disability changes. In the case of Sylvia R., on January 22, 2011, in order for her to qualify for continued benefits, she must at that time prove that she is unable “to perform the material duties of any occupation that her education, training or experience reasonably allow.” This is obviously a much higher standard to satisfy as it could mean “any occupation” under the sun. The Court’s opinion is silent on whether there is an earnings requirement in the GAF Materials Corporation LTD Policy, however many policies require that this “any” occupation provide an income of at least 60% of the prior monthly earnings of the disabled person.

Most insurance companies use this change in definition as a perfect excuse to deny a person’s claim and to end benefits. In fact, a great percentage of people that contact Attorneys Dell & Schaefer Chartered due so after they have been denied for this very reason. Thus, it is important for all people who are currently receiving disability benefits to be aware if their policy contains this “change in definition of disability” and if it does, one must also be aware of the date in which the definition will change.

If one knows of the date that the definition will change, they can either attempt to strengthen their case or prepare economically for an upcoming denial of benefits (and a termination of income) prior to that time.

Unfortunately in the case of Sylvia R., Reliance Standard utilized the change in definition as a perfect time to deny Sylvia R.’s claim. Although administrative appeals and this lawsuit were filed, the Court upheld Reliance Standard’s decision to deny benefits. The Court felt that the five independent physician reviews conducted by Reliance Standard was sufficient evidence enough to support its decision to deny benefits. It is unknown what evidence, if any, Sylvia R. provided prior to and after the denial of her claim.

If you are currently on claim and are in fear of being denied continued disability benefits by Reliance Standard or any other insurance company due to this change in definition of disability, please contact Attorneys Dell & Schaefer Chartered for a free consultation so that we can assess your claim and see if we can be of assistance in strengthening your claim prior to a possible denial.

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