Case Examples

Back/Spinal Injury

Gloria Archuleta worked as a Customer Service Representative, for Hub Industries. Her job required constant sitting. Ms. Archuleta began to experience severe pain and sudden attacks on her right side, which rendered it impossible for her to sit for more than brief periods. Ms. Archuleta underwent surgery and was subsequently prescribed strong pain medication to alleviate her continuing pain. Ms. Archuleta’s doctors consistently supported her disability and advised the insurer that plaintiff’s ability to perform her job was impaired by not only her pain, but her strong pain medication. The trial court held, in a published opinion, that Reliance Standard acted in an arbitrary and capricious manner when it terminated the benefits. The insurer ignored Ms. Archuleta’s reports of pain and failed to investigate or consider the side effects of her pain medication. Archuleta v. Reliance Standard Life Ins. Co ., 504 F.Supp2d 876 (C.D., Cal, 2007).

Cardiac Condition

Dr. Abdel Malek is a physician at Kaiser, where he had to discontinue his full time practice due to a cardiac condition. He had been advised to work only part time because the stress of his full time job increased the possibility of a serious heart attack. Kaiser’s disability insurer, CIGNA, refused to pay Dr. Abdel Malek his disability benefits, stating that if Dr. Abdel Malek was “capable” of working part time, he was “capable” of working full time.
The case was tried and the trial court issued an opinion which was published. The trial court found for Dr. Abdel Malek and stated that the severe risk associated with a full time practice was sufficient grounds for disability status. The Court stated: “...it would be unreasonable to interpret “capable” to mean “capable until your condition kills you.” . Abdel Malek v. Life Ins. Co. of N. America , 359 F.Supp2d 912 (C.D., Cal, 2005).

Chronic Fatigue Syndrome

Kantor & Kantor, LLP represented cameraman suffered from chronic fatigue syndrome and was unable to perform the duties of his occupation. His claim was denied by his disability insurer, who failed to conduct any meaningful investigation of the claim.

Kantor & Kantor, LLP filed suit and after a brief period of discovery filed a motion for summary judgment, requesting the Court to enter judgment in plaintiff's favor without a trial, and as a matter of law. The Court granted our motion for summary judgment. As a result, our client received all benefits under his policy up to age 65, a significant amount of damages for emotional distress and payment for his attorneys' fees, for a total of over $900,000.

Degenerative Disc Disease

Sonya Schvartsman managed the Quality Control Department of a large chemical company for 22 years. After 22 years of employment, Ms. Schvartsman could no longer perform the duties of her job, which required light lifting and extensive walking, due to degenerative disease in her back, pulmonary difficulties and depression. The insurer for the employer, Prudential Insurance Company, initially approved her claim. However, 10 months later, Prudential terminated her benefits, without obtaining updated relevant records. Ms. Schvartsman appealed and during the appeal, Prudential sent her claim file to a physician to obtain a second opinion. The physician supported Prudential’s termination.
At trial, the Judge remanded the case back to Prudential to permit Ms. Schvartsman to submit evidence rebutting the opinion of Prudential’s reviewing physician. Kantor & Kantor, LLP discovered that the physician was not experienced in the field and that his “expertise” appeared to be limited to cosmetic procedures, such as Botox injections. After receiving this evidence, Prudential reversed its claim decision and Ms. Schvartsman was awarded her back benefits. Schvartsman v. Prudential Ins. Co. of America, Civil Action No. CV05-1950 PA (Ex)

Depression - Addiction

Kantor & Kantor, LLP represented a doctor seeking benefits due under three policies of disability income insurance. Our client was rendered totally and permanently disabled from his former occupation as an anesthesiologist due to severe depression and narcotic addiction, as defined under the disability insurance policies. Defendants unreasonably denied our client's claims without justification, and terminated his claims in reckless disregard of his rights as an insured. The insurers' bad faith was evident from their conduct. They failed to properly investigate our client's claim, they ignored the opinion of our client's treating physician, they misrepresented facts to our client, and they failed to obtain an independent medical examination.
We settled the case favorably for our client.

Eating Disorder

Our client came to Kantor & Kantor, LLP after unsucessfully seeking treatment from Kaiser for a severe eating disorder (bulimia). For four months, she tried to obtain appropriate treatment, but Kaiser offered only inconsistent appointments with unqualified personnel. Without appropriate treatment, her condition worsened and she became suicidal. Even at that point, Kaiser advised our client that there was no appropriate treatment program available within the Kaiser system. Our client’s family researched the question and found a program that was designed specifically to treat the condition. Pursuant to the terms of her Plan, our client requested Kaiser to authorize a referral to that program, and that Kaiser pay for her treatment. Kaiser refused.
Fearful for her daughter's life, our client's mother arranged to admit her to the program at the family’s expense. Our client remained in a special facility as an in-patient for about a month. On appeal, Kaiser upheld its denial of the claim, and never even responded to our client's request for a list of available providers within the Plan.
Based on our lawsuit, the court held that Kaiser's behavior was wrongful, unreasonable, irrational, and contrary to the evidence, the terms of the Plan and applicable law. Kaiser was further ordered to pay all fees and costs of our client's treatment, and attorney’s fees and costs related to the litigation. You can read the court order by clicking here.

Fibromyalgia

Kantor & Kantor, LLP represented a Customer Care Advocate who suffered from fibromyalgia. Plaintiff's job was largely sedentary, requiring that she sit at her desk for nearly all the work-day. After several short-term disability leaves, plaintiff filed for long-term benefits. Despite reports from her doctor indicating that she was unable to perform her job duties, plaintiff's claim was denied. Plaintiff appealed this decision, included additional doctor's reports and statements from family and friends describing her deteriorating physical condition, but was repeatedly denied benefits.

The Court, after a de novo review of defendant's denial, overruled defendant's administrative decision, entering judgment for the plaintiff. Plaintiff's long-term disability benefits were resumed and defendant was ordered to pay plaintiff's attorney fees.

Fibromyalgia & Chronic Fatigue

Kantor & Kantor, LLP represented an accountant who suffered from chronic fatigue and fibromyalgia. Her claim was denied by her disability insurer who failed to adequately consider plaintiff's attending physician's diagnosis of total disability.

Kantor & Kantor, LLP filed suit and the Court granted summary judgment for plaintiff, finding a conflict of interest existed which showed defendant's denial of benefits was unreasonable. Defendant was ordered to pay disability benefits to plaintiff.

Fibromyalgia & Chronic Fatigue

Defendant Paul Revere approved plaintiff's long-term disability benefits claim under the "Other Limitations" policy provision which covers psychiatric conditions, and was therefore subject to the 24-month policy limitation for disorders caused or contributed by a psychiatric disorder. Plaintiff, who suffered from fibromyalgia and chronic fatigue, initiated an administrative appeal of Defendant's decision which was denied.

Kantor & Kantor, LLP filed suit and after a bench trial, judgment was entered in favor of the plaintiff. Defendant was ordered to resume payment of long term disability benefits in accordance with the policy.

Fibromyalgia & Chronic Fatigue Syndrome

Kantor & Kantor, LLP represented an attorney who, after years of successful practice, became totally disabled due to Fibromyalgia, Chronic Fatigue Syndrome, and a sleep disorder. Before coming to us for help, she had filed her own disability claim, and after it was denied, she filed an appeal. Despite our client's repeated requests to her insurer for an independent medical examination, and despite medical opinions from various treating doctors supporting our client's disability, her claims were denied. The insurer justified its continued denials based upon a review by one of its own in-house nurses and the opinions of another doctor who never examined her.
We filed a lawsuit and argued that the insurance company failed to adequately investigate our client's claims, ignored pertinent evidence establishing her disability, and refused to entertain reasonable requests from our client. We settled the case to the satisfaction of our client.

Life Insurance

Hartford Insurance Company offered a supplemental life insurance program to the employees and their families of Sargent Fletcher. Our client, Donald Gaines signed up for the Supplemental Life Insurance, purchasing coverage for his wife. The life insurance premiums were deducted from his paycheck for five months and transmitted to Hartford. After five months, Mrs. Gaines passed away unexpectedly and Mr. Gaines filed a claim for the benefits. Hartford denied Mr. Gaines’ claim, stating that the employer failed to submit the proper paperwork when it enrolled its employees in the life insurance plan.
We brought suit against both the employer and Hartford and we were successful inobtaining a verdict in our client’s favor. The trial court held that the Policy was ambiguous as to what type of paperwork was required to be submitted to properly enroll in coverage and that after accepting premiums, the insurer could not deny the claim. Gaines v. The Sargent Fletcher, Inc. Group Life Ins. Plan, 329 F.Supp2d 1198 (C.D., Cal., 2004).

Life Insurance

Through his employer, our client obtained accidental death life insurance for his wife. Mrs. McKean underwent minor surgery for an injury she sustained in a trip and fall accident. After the surgery, Mrs. McKean went home, went to bed and died unexpectedly that evening in her sleep. Mr. McKean submitted a claim for the life insurance benefits, on the basis that his wife’s trip and fall was an accident; entitling him to benefits. Aetna Life Insurance denied the claim, relying on a provision in the Policy that losses due to a “bodily or mental infirmity” were excluded under the Policy. However, in denying the benefits, Aetna ignored another provision in the Policy which provided benefits for losses “due to surgery when needed for an injury.” The Trial Court interpreted the Policy in plaintiff’s favor and awarded benefits. McKean v. Aetna Life Ins. Co., Civil Action No. EDCV 04-01104 (Central District of California, Eastern Division).

Life Insurance

Kantor & Kantor, LLP represented Plaintiff who sought payment of a life insurance policy after his wife died. Defendant's refused to pay more than $20,000 of the $150,000 policy despite Plaintiff's timely payment of premiums on disclosure of all information solicited by Defendant.

Kantor & Kantor, LLP filed a motion for summary judgment, requesting the Court to enter judgment in plaintiff's favor without a trial, and as a matter of law. The court granted our motion for summary judgment. As a result, our client received all benefits under his policy and payment for his attorneys' fees, for a total of over $150,000.

Life Insurance

Our client's husband died in a tragic bicycle accident. When she made a claim for benefits under his employer provided life insurance policy, the insurance company refused to pay. Its reason was that the husband had failed to properly complete the insurance enrollment forms. While it was true some of the forms were not filled out, the fact of the matter is that no one ever provided him with the forms or oterwise asked him to fill them out. We filed suit against the employer and the insurance company, and after about 5 months were able to enter into a favorable settlement agreement.

Life Insurance

Malignant brain cancer took the life of the husband of another of our clients. He too had life insurance through his employer. It was a $1,000,000 policy. When his wife made a claim, the insurance company denied it in part saying that her husband was only entitled to $500,000 in benefits because he did not complete an "evidence of insurability" form. No one ever provided him with, or told him to complete an evidence of insurability form. Moreover, the employer had been deducting premiums from his paycheck representing payment for the full $1 Mil in insurance. We filed suit against the employer and the insurance company to force them to pay the remaining $500,000 in benefits. After about 3 months, we were able to settle this case to the satisfaction of our client.

Long Term Care Benefits

Our client, Mr. Frank, purchased a Long Term Care policy many years ago for both himself and his wife. The insurance company eventually became Conseco Senior Health Insurance Company and then, due to some interesting financial difficulties, morphed again into Senior Health Insurance Company of Pennsylvania also known as S.H.I.P. When Mr. Frank's wife became ill and needed home health care, he submitted the bills and paperwork related to that home health care to S.H.I.P. for payment. S.H.I.P. refused to pay benefits on the grounds that the home health care agency Mr. Frank had hired was not appropriately licensed or federally certified to provide Home Health Care. The fact is, however, that California does not require any specific license related to providing home health care services.

After we filed a lawsuit in Federal Court for Mr. & Mrs. Frank, S.H.I.P. immediately agreed to pay benefits, and acknowledged that they had made a mistake in the original denial.

If you have a Long Term Care policy that provides benefits for "Home Health Care Services," or services from a "Home Health Care Agency," "Personal Care Services" or "Instrumental Activities of Daily Living," and benefits have been denied, we may be able to help.

Long Term Care Benefits

Kantor & Kantor, LLP represented an 88-year old woman in her pursuit of benefits under a Long Term Care Policy. Our client submitted a claim because she could no longer attend to her basic daily activities and needed a home health aide to assist her. The Long Term Care policy expressly provided for these types of benefits. Our client complied with all of her obligations under the Policy and submitted proof of her need for a care-giver from her doctor, her daughter, and the care-giver herself. Her insurance company denied the claim. We argued that the denial was made in bad faith due to failure to properly investigate the claim, a failure to notify the client of the reasons for denial, and failure to comply with California law regarding obligations of insurers in handling claims. We settled the case favorably.

LUPUS - Disability

Our client, Mrs. Wible, was an employee of The Boeing Company. She came to Kantor & Kantor, LLP for help in obtaining Long Term Disability (LTD) benefits from Aetna. While employed, Mrs. Wible became totally disabled due to Lupus, and was thus entitled to benefits under the LTD Plan of the Boeing Company.
Her claim was initially paid by Aetna, but was then later denied. Mrs. Wible appealed the denial. Tragically, while the appeal was pending, Mrs. Wible died from complications of her Lupus.
Incredibly, even though Mrs. Wible died as a result of Lupus within just six months of the date that Aetna determined she was no longer disabled, Aetna denied her appeal post-mortem. We succeeded in getting a Court order stating that Aetna ignored, or at best, discounted the credible evidence of her disability. That evidence included the opinions of Mrs. Wible's long-time treating physician, Aetna's own physician who reviewed Mrs. Wible's file, Aetna surveillance evidence and the Social Security Administration findings of Mrs. Wible's disability. The Court found that Aetna was "bent on denying" Mrs. Wible's claim and oblivious to its fiduciary obligations as an LTD Plan administrator. You can read the court order by clicking here.
Aetna paid 100% of all benefits and attorneys fees.

Multiple Sclerosis

Ms. Gullidge was a former Title Examiner for First American Title and participated in her employer’s long term disability plan. Ms. Gullidge was diagnosed with Multiple Sclerosis in the early 1980's, but continued to work until 2002. She submitted a claim for disability benefits due to her progressive weakness and fatigue. Hartford Insurance Company approved of plaintiff’s claim and Ms. Gullidge was also awarded Social Security disability benefits. Hartford then sent a confusing letter to Ms. Gullidge’s physician, asking him if Ms. Gullidge could perform “sedentary work,” even if she could only sit for less than 3 hours a day. The physician misunderstood the letter and then later corrected his statement and advised Hartford that Ms. Gullidge was absolutely disabled. Hartford refused to accept the correction and terminated plaintiff’s benefits.
After litigating the case for several months, Hartford unilaterally decided to reverse its claim decision and reinstated Ms. Gullidge to her benefits.

Parkinson’s Disease

Our client was an Office Manager for Edward Jones and required back surgery. When her recovery from surgery did not progress as anticipated, she underwent Neurological testing, which revealed that she suffered from Parkinson’s Disease. When she advised Continental Casualty that she would not be able to return to work as previously anticipated, the insurer refused to pay further benefits. Hartford Insurance Company then assumed the obligations under the Policy and had our client’s records reviewed by a medical reviewing service that it routinely uses. Kantor & Kantor, LLP successfully tried this action and the trial court found that Hartford erroneously evaluated plaintiff’s disability, using a “sedentary occupation” standard when the insurance policy only required that one be disabled from their own occupation. Rorabaugh v. Continental Cas. Co ., 2006 WL 4384712 (C.D., Cal, 2006).
Hartford then appealed the trial court’s verdict and the Ninth Circuit upheld the decision in favor of our client. Our client was awarded benefits from August, 2005 to the present. Rorabaugh v. Continental Casualty Company , 321 Fed. Appx. 708, 2009 WL 979885 (9th Cir., 2009).

Shoulder Impingement

The plaintiff worked as a Support Assistant for Safeco Insurance Company. In 2000, Ms. Broderick began to experience problems with her shoulders, elbows and hands. She was eventually diagnosed with “frozen shoulder” and carpal tunnel syndrome. Although Prudential paid her benefits for two years, it terminated her benefits after 2 years, claiming that Ms. Broderick could perform another occupation for which she was suited by virtue of her “education, training and experience.” However, Prudential failed to realize that Ms. Broderick’s medical conditions made it impossible for her to reach and type, which were activities required for any suitable alternative occupation. The trial court agreed and rendered judgment for plaintiff. Broderick v. Prudential Ins. Co. of America, Civil Action No. CV04-0719 GAF (Central District of California)

Vision Problems

Our client, Carl Barteau was a former College Professor, who had always experienced vision problems. However, in 2002, his vision worsened and the treatment which he received caused extreme pain and migraines. In addition, Mr. Barteau suffered from multi disc degeneration in his back. The insurer for his employer, Prudential Insurance Company, paid Mr. Barteau’s benefits for several years and then terminated his benefits without any signs of improvement in Mr. Barteau’s condition. Rather, to support its claim termination, Prudential had Mr. Barteau’s claim file reviewed by a physician it routinely uses in its claims administration, Dr. Steven Gerson. The case was brought to trial and the Court held that Prudential erroneously terminated the benefits without any signs of improvement. In addition, the trial court found that Dr. Steven Gerson did not provide a full and fair assessment of Mr. Barteau’s disability, but rather, had acted as an advocate for Prudential. Mr. Barteau was awarded his back benefits and was reinstated to the Plan. Barteau v. Prudential Ins. Co. of America, 2009 WL 1505193 (C.D., Cal, 2009).

After working for his employer for over 35 years, Samuel Toven submitted a disability claim due to an eye injury, diabetes and depression. Although Social Security recognized that Mr. Toven was disabled from “any occupation,” his employer’s insurer, Metropolitan Life Insurance Company, refused to grant him disability benefits. Kantor & Kantor, LLP successfully fought to take the depositions of MetLife’s claim representatives and used that testimony at trial to obtain a victory for Mr. Toven. Mr. Toven’s back benefits were paid and he was reinstated to the Plan. Toven v. Metropolitan Life Ins. Co., 2008 WL 5101727 (C.D., Cal, 2008).

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