Sometimes it is not the long term disability insurance company that makes life miserable for our clients. In this case, our client’s benefits were terminated by the third party administrator, the outside company that manages disability insurance and other insurance programs on behalf of his self-insured employer. This is not as uncommon as it used to be, as many large companies have moved to self-insurance to control insurance costs. When they do, typically they outsource claim decisions to a third-party, who has the same goal as the employer – to reduce costs of the plan and limit benefits.
When it’s your long term disability insurance benefits, you don’t care who has made the decision to terminate your benefits. You just want them reinstated. For our client, the termination made his condition worse.
Our client is a fifty year old male with Multiple Sclerosis (MS), a degenerative musculo-skeletal disease that is exacerbated by anxiety and stress.
He had complied with a request from Sedgwick, the third-party administrator, to have an Independent Medical Examination (IME), despite the fact that a prior IME had found that he was unable to work in his prior occupation as a Design Support Engineer. We know from experience that the only reason Sedgwick asked for a second IME was to find another doctor who would deliver what they wanted, and help support a reason to stop paying his benefits.
Frankel & Newfield engaged Sedgwick to interact with us. We first got Sedgwick to allow a third IME to be conducted, and to agree to pay our client his monthly Long Term Disability insurance benefits while the third IME process was pending.
We next negotiated with Sedgwick to allow the third IME to be conducted by a physician who was truly neutral and not in the third party administrator’s pocket or on their payroll. By fighting to get a medical examination that was truly independent and unbiased, we were able to present our client’s medical condition in an honest manner. The third IME demonstrated that our client was indeed not able to perform the tasks and duties of his occupation.
Our client is now getting paid, without any reservations of rights.
This is an example of disability insurance matters that can be resolved through negotiations, knowledge of the claims process, and a skill set that works in and out of the courtroom.