By | March 17, 2015

In a case not handled by Attorneys Dell & Schaefer, but which can be utilized to our clients’ advantage in the future, a Long Term Disability (LTD) Claimant has earned a partial victory against Standard Insurance Company.

Ms. Annina Puccio was forced to make a claim for disability benefit after suffering from numerous disabling medical conditions. Ms. Puccio initially left her previous occupation as the Senior Manager of Assessments and Certification at NetApp Inc. on January 28, 2009 due to an unsuccessful gastric bypass surgery to treat bariatric issues. After initially denying her application based on “outside physician consultant” reviews, after the filing of an administrative appeal by Puccio Standard relented an approved her claim on October 2, 2009.

However, Standard only found her disabled due to a mental health condition and informed Puccio that such conditions were limited to 24 months of benefits due to the fact that her ERISA Long Term Disability Policy limited benefits for such disorders to 24 months.

Prior to the end of the initial 24 months of benefits, Ms. Puccio submitted additional medical documentation which showed that she suffered from additional physical disabilities that qualified her for LTD benefits beyond the 24 month mental health limitation. Such records showed a recent diagnosis of fibromyalgia as well as 15 other chronic conditions which Puccio suffered from including asthma, bipolar disorder, esophageal dysmotility and osteoarthritis. Standard was also informed that Ms. Puccio’s claim for Social Security had been approved.

Unfortunately for Ms. Puccio, the additional information and documentation was not enough for Standard which denied her claim. Standard again based its decision on an “outside physician consultant” review. Ms. Puccio again appealed and Standard again relented and re-approved her claim. This time Standard found her to be disabled by fibromyalgia and osteoarthritis which, under the LTD plan’s terms, were limited to a maximum of 24 months of benefits. Thus, Standard would pay her only until February 3, 2013.

Prior to February 3, 2013, Puccio submitted additional medical records including a diagnosis of Addison’s disease. Standard acknowledged the new diagnosis and the new medical records and Standard also asked to be repaid the overpayment owed to it due to Ms. Puccio’s award of Social Security Disability Benefits. Standard also reduced the amount of the monthly LTD benefit due to the offset of the Social Security Disability Benefit. It must be noted, however, that Standard never reviewed or even requested the decisions, evaluations or records of the Social Security Administration on Puccio’s claim.

Standard’s “outside physician consultant” again reviewed Puccio’s records and concluded that only fibromyalgia and osteoarthritis were disabling and not any other condition. Standard did not have an in-person medical evaluation conducted. Puccio’s claim was again denied and after the filing of the administrative appeal, which was also denied with solely the help of “outside physician consultants” and no in-person evaluation, Litigation commenced.

The Court’s Ruling

The Court first noted that “Standard forthrightly acknowledges, Puccio has experienced a number of health problems and is disabled.” “The only dispute is whether her disabilities are covered by the LTD policy or whether she has exhausted the maximum benefits allowed under the policy for her particular conditions.”

The Court found that “Standard abused its discretion when it denied plaintiff LTD benefits beyond the mental health and musculoskeletal coverage.” The Court felt that Standard “should have conducted an in-person medical evaluation to assess the disability impact of Puccio’s Addison’s disease, gastrointestinal problems and other issues.” While the Court noted that such in-person claims are not mandatory in all ERISA LTD reviews, in this instance, one should have been conducted due to “the complexity of Puccio’s health conditions, and the volume of her medical records, and their lack of clarity…”. The Court also noted that “Standard’s team never even spoke with any of Puccio’s treating physicians about her records or status.

Instead, Standard limited itself purely to a paper review of her medical records at the cost of ascertaining all the facts from an in-person exam. That alone raised questions about the thoroughness and accuracy of the benefits determination.”

Furthermore, the Court noted that “Standard made no effort to obtain, let alone consider and meaningfully distinguish, the SSA’s award of disability benefits to Puccio.” This was in light of the fact that Standard knew about the SSA award and even seized the overpayment and decreased future LTD benefits.

Lastly, the Court noted that in denying her claim, Standard never advised Puccio of the “additional information it considered useful to review her claim.” This is required under ERISA as a claimant is entitled to a “description of any additional material or information that was necessary for her to perfect the claim, and to do so in a manner calculated to be understood by the claimant.”

Altogether, the Court found that Standard has abused its discretion in denying Puccio’s claim. The Court remanded the claim back to Standard because “it is impossible to know how the plan administrator (Standard) would have acted had it not abused its discretion.” The Court ordered Standard to allow Puccio to “supplement her file with any additional medical records necessary to evaluation plaintiff’s disability.”

Why Does This Decision Matter?

This decision can be utilized as an educational tool for those with active claims with Standard. Furthermore, it can be used during litigation with Standard or any disability insurance provider.

If you have been denied Long Term Disability benefits by Standard or any disability insurance provider and you need to appeal or sue, please do not wait any longer and please contact Attorney Alexander Palamara or any attorney at Dell & Schaefer. We are always available for a free consultation.

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