MS Insurance Lawyers in California
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If you or a loved one have MS and need help getting health related insurance claims paid, please contact us. Whether you are dealing with an ERISA or non-ERISA governed claim for Disability Health, or Life Insurance, or a claim for Long Term Care benefits, we can help.
For over 20 years we have been successfully representing individuals with MS, both in the appeals of denied claims, and in Federal Court litigation. There is no charge for an initial consultation.
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Multiple Sclerosis Cases
Letvinuck v. Aetna Life Ins.Co., 319 Fed.Appx. 661 (9th Cir. June 22, 2011)(unpublished)
In approximately 2003, Letvinuck was diagnosed with Multiple Sclerosis, but continued to work despite symptoms of fatigue and cognitive decline. After attempting to work from home, Letvinuck submitted a claim for disability to her employer's claim administrator, Aetna. Aetna also funds the benefits to be paid under the Plan. Aetna initially approved Letvinuck's claim under the employer funded short term disability phase of the Plan. As Aetna's own liability approached, under the long term phase of the Plan, Aetna terminated Letvinuck's disability benefits. Suit was filed in Federal Court. After a prior remand because the district court failed to apply the appropriate standard of review, the Ninth Circuit again heard plaintiff's appeal because the district court again ruled for Aetna. This time, the court reversed outright based on Abatie v. Alta Health & Life Ins. Co., 458 F.3d 955, 962 (9th Cir. 2006) (en banc), Metro. Life Ins. Co. v. Glenn, 554 U.S. 105, 108 (2008), and Montour v. Hartford Life & Acc. Ins. Co., 588 F.3d 623, 630-31 (9th Cir. 2009). The court found several errors in Aetna's determination: First, Aetna gave no consideration to a Social Security award. Although the court did not deem that award binding on Aetna, "not distinguishing the SSA's contrary conclusion may indicate a failure to consider relevant evidence." Montour, 588 F.3d at 635. The award was not mentioned at all when benefits were denied and only acknowledged, but never distinguished, when the denial was upheld. Although Aetna told the plaintiff after the appeal was denied that Social Security uses different standards, the court ruled that failure to address it offers support that the plan administrator's denial was arbitrary, an abuse of discretion." Salomaa v. Honda Long Term Disability Plan, F.3d , 2011 WL 2040934, at *11 (9th Cir. 2011).
Second, Aetna failed to adequately communicate to Letvinuck what additional material or information was necessary to perfect her claim as required by ERISA according to Saffon v. Wells Fargo & Co. Long Term Disability Plan, 522 F.3d 863, 870 (9th Cir. 2008). Aetna never told the plaintiff what was missing at a time when she could have obtained and submitted such documentation. Although Aetna left a voice mail with her treating doctor seeking "clinically objective findings," that was not enough according to Saffon, 522 F.3d at 873 (communicating with a doctor rather than the Plan participant is not meaningful dialogue). Aetna also denied benefits without examining her. As Montour held, a "pure paper" review of a Plan participant's claim "raises questions about the thoroughness and accuracy of the benefits determination." Because Aetna failed to engage in "a meaningful dialogue" with the claimant, its decision was deficient.
For those reasons, Aetna's decision was viewed "with a high level of skepticism" which caused the court to conclude that Aetna abused its discretion in denying benefits.
The court thus held Aetna based its denial of benefits on the absence of specific medical evidence - evidence that Aetna did not tell Letvinuck she should obtain and send to Aetna to perfect her claim. Aetna did not meaningfully explain why it disagreed with the SSA's award of disability benefits, and only attempted to do so when Letvinuck called Aetna after it had already denied her appeal. Therefore, we reverse the district court's judgment in favor of Aetna and remand to the district court with instructions to direct an award of benefits.
Discussion - Although this ruling is unpublished and therefore non-precedential, it is still extremely instructive. The two key issues raised by the court (failure to distinguish Social Security and failure to inform the claimant what evidence is needed), along with the sub-issue – the skepticism raised by a pure paper review and lack of examination – are major points to keep in mind as a checklist in future litigation.
Kreeger v. Life Insurance company of North America, (C.D. Cal. 2011) 766 F.Supp.2d 991
Margaret Kreeger, a 57–year–old woman who formerly held a high level position as in-house counsel at BP Corporation North America, Inc. (“BP”), suffers from multiple sclerosis (“MS”). The condition was first diagnosed in 1988, but Ms. Kreeger managed to continue working without accommodation for ten years. In 1998, due to the progress of the disease, Ms. Kreeger's work schedule was modified to permit her to work three days at the office and to tele-commute two days each week. However, in December 2005, due to further deterioration in her condition, including distress due to memory dysfunction, chronic depression, anxiety and pathological fatigue, she was no longer able to work. In May 2006, Ms. Kreeger applied for long term disability benefits pursuant to her employee benefits plan and began receiving her requested benefits a month later. Life Insurance Company of North America (“LINA”), which funded and administered the disability benefits plan, approved the application. However, on May 8, 2008, LINA notified Ms. Kreeger it was terminating her benefits effective April 30, 2008. While Ms. Kreeger sought to reverse this decision on appeal, LINA affirmed its denial of benefits on October 29, 2008. Ms. Kreeger retained Kantor & Kantor, LLP to commence legal action against LINA. A complaint was filed in U.S. District Court on November 12, 2009, alleging a cause of action under the Employee Retirement Income Security Act of 1974 (“ERISA”). In that action, Ms. Kreeger contended that Defendants LINA and BP Welfare Plan Trust–III's Insurance Plan wrongfully terminated her benefit payments. She sought reinstatement of those benefits, payment of back benefits, and interest to the date of Judgment. On February 28, 2011, the Court found for Ms. Kreeger and ordered Defendants to pay benefits. The Court’s order was based primarily on the fact tht LINA failed to act fairly and reasonably in administering Ms. Kreeger’s claim because it failed to 1) conduct a medical exam of Ms. Kreeger; 2) Provide all relevant medical evidence to the doctors it hired to review her records; 3) give reasonable consideration that the Social Security Administration’s award of disability benefits; 4) appeared to be motivated by protecting its own financial interests and failed to show that any measures had been taken to minimize the effects of that financial bias.
Gullige v. Hartford
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.
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