An Arkansas District court found that USAble Life misapplied the definition of disability when denying a mental health professional’s long-term disability benefits. Before her disability, Ms. Dinora Reyes worked as a mental health professional for Western Arkansas Counseling & Guidance Center, Inc. After suffering a fall which resulted in severe neck, joint pain, headaches, infection, and fatigue, Ms. Reyes submitted a claim for LTD benefits with USAble Life.
USAble Life initially denied her claim, stating she could perform her own occupation. USAble cited, in part, that Ms. Reyes occupation was a sedentary one. During its initial review, USAble had a nurse review the records from seven of Ms. Reyes’ treating physicians. During the claims review process, Ms. Reyes was awarded disability benefits from the Social Security Administration. Ms. Reyes appealed USAble’s decision and included medical records supporting her inability to work in a sedentary occupation.
In its review of Ms. Reyes’ appeal request, USAble had a consulting physician review the medical records. Based on this physician’s paper-based review, USAble denied the appeal. After again unsuccessfully appealing USAble’s decision, Ms. Reyes filed a lawsuit seeking her long-term disability benefits.
Paper-based reviews of disability claims and appeals are very typical behavior of insurance companies. Dabdoub Law Firm only focuses on ERISA and disability insurance claims. We have helped numerous people whose benefits were wrongfully terminated by disability insurance companies.
The Court’s Review
At the onset, the Arkansas court noted USAble failed to identify the “material and substantial duties” of Ms. Reyes occupation - an important issue as it is part of the definition of disability under the policy. Under the policy, Ms. Reyes was disabled if she could not perform one or more of the material and substantial duties of her occupation. The court noted USAble only focused on the physical demands of her occupation and nothing else. As a result, the court found USAble failed to provide Ms. Reyes with a “full and fair review” as required under ERISA. Because USAble did not fully investigate the claim, it reasoned, the court could not determine whether or not the insurance company properly denied Ms. Reyes claim. To be sure, the court noted USAble had left Ms. Reyes’ record factually incomplete.
As a result, the court remanded the case - or sent the claim back - to USAble with instructions to evaluate Ms. Reyes’ claim in light of the definition of disability as written in its policy. The court instructed USAble to (1) identify the material and substantial duties of a mental health professional, and (2) give full consideration to each and every one of those duties, not just the physical demands.
Having an Experienced Disability Attorney Matters
Disability insurance law is complicated. If your claim for long term disability benefits was denied or being delayed by an insurance company, it is important to get legal help from a lawyer who focuses on disability law.
As a law firm built to focus disability insurance, all our disability lawyers spend every day working to get our clients disability benefits from insurance companies.
Because federal law applies to most disability insurance claims, we do not have to be located in your state to help.
Dabdoub Law Firm represents clients nationwide with:
- submitting a disability insurance claim;
- appealing a long-term disability denial;
- negotiating a lump-sum settlement; or
- filing a lawsuit against your disability insurance company.
Because each client’s case is unique and has different facts, results similar to those in other clients’ cases are not guaranteed.