Disability Insurance Benefits

Disability Benefit Claims

North Carolina Disability Benefit Attorneys

Mr. Whiteman has been retained as counsel in over 300 cases involving disability benefits claims and has represented clients in over 45 court cases.

We represent individuals who have claims for:

Short-term and long-term disability benefits
Disability pensions
Denial of benefits under individual or group disability insurance policies
ERISA disability claims
FMLA claims
Group life insurance

We will review the facts of your case on a confidential, no-cost basis and advise you on your options for recovering disability benefits. Please contact us.

Claimants should be aware of the following:

Employee benefits are controlled by ERISA

Disputes involving employee benefits are governed by a federal statute, known as ERISA, which stands for the Employee Retirement Income Security Act of 1974. A law that deals with “employee retirement income security” sounds friendly, however, ERISA provides significant advantages for the employer or insurance company.

In an ERISA case, the claimant is not entitled to a jury trial. Usually, there is no trial at all. Typically, the court’s role is limited to reviewing the plan document and the claim file to determine whether the claims administrator abused its discretion. Under this limited standard of review, the claims administrator’s decision will be upheld if it is “reasonable.” The claims administrator does not have to give greater weight to the claimant’s treating physician and may decide to accept the evaluation of one of its own staff physicians, even if that doctor never examined the claimant. ERISA restricts the court’s review to documents that were available to the claims administrator at the time it issued its final decision. Evidence obtained after the claimant has exhausted his or her administrative appeal rights cannot be considered by the court. Therefore, it is of paramount importance that the claimant develops fully the evidence in support of his claim and submits such evidence to the claims administrator during the claim process.

Non-ERISA disability cases are governed by state law

Holders of individual disability policies have significant advantages over those whose benefits are provided through an employee benefit plan. An individual disability policy is a contract with an insurance company. If the insurance company denies the claim for benefits, the claim is governed by state law. The claimant has the right to file a lawsuit in state or federal court. The claimant has the right to bring witnesses to the trial to support the claim, and the dispute will be resolved by a jury. In addition to the claim for breach of contract, the claimant might be able to raise additional claims if the insurer’s refusal to pay constitutes bad faith. Many states, including North Carolina, have state consumer protection statutes that allow recovery of treble damages and attorney’s fees. Punitive damages may be available if the insurance company’s conduct is bad enough.

There are time limits for acting

Private disability insurance is governed by the wording of the policy. If the insured pays the premiums, the policy remains in force and the insured may submit a new claim for benefits at any time. When the claim involves an employee benefit plan, the plan documents and ERISA provide important time limits. The claimant may lose eligibility If he does not claim disability before the termination of employment. If the claimant does not appeal within 180 days, the claimant may lose his right to claim benefits.

The claimant must exhaust administrative remedies

In an ERISA case, the claimant must proceed through the claim submission and appeal process before he Is allowed to file suit. The failure to exhaust administrative remedies before filing suit usually results in dismissal.

Claimants have important rights

Claims administrators are required to provide a detailed explanation of why the claim was denied and to advise claimants of their right to appeal. Claimants have the right to request that the claims administrator produce plan documents and the claim file. It is imperative that the claimant or his attorney obtain the claim file to evaluate the claim administrator’s evidence and to determine what additional evidence should be submitted.

Support from health care providers is essential

A successful claim requires strong documentary support from healthcare providers. It is usually necessary for the claimant’s doctors to work with the claimant or his attorney to carefully rebut the claims administrator’s arguments. The claimant’s medical records must support a finding of disability.

Understanding the definitions

Most policies contain two or three definitions of disability. These are known as “own occupation,” “any occupation” and “residual disability.” In addition, many employer-sponsored plans provide limited benefits for disabilities caused by mental illness or self-reported symptoms.

Generally, disability coverage offered by an employer will provide that a claimant will be considered disabled if he is unable to perform “the material and substantial duties of his occupation,” or sometimes “each and every material duty of his occupation.” The meaning of those phrases is sometimes not readily apparent. The term “occupation” is broader than “job.” Job duties that are not generally required to perform the occupation will be disregarded in assessing disability. Therefore, when the appeal involves the “own occupation” definition, the starting point should be a detailed job description and an assessment of whether the claimant is unable to perform each of the duties on a full-time basis.

Employee benefit plans usually provide that after two years the claimant will be considered disabled only if he is unable to perform “any occupation for which he is reasonably suited by reason of age, education or experience.” This is a harder definition to meet, as it requires proof that there is no gainful occupation that the claimant can perform.

Disclaimer: Please note that the information on this page is provided for general information purposes only and may not reflect current law in your jurisdiction. The information contained herein should not be considered legal advice. You will not be considered a client of Whiteman Law Firm until we have signed an agreement for legal representation.

Reported Decisions

Court of Appeals

This case involved a dispute about the meaning of convoluted plan provisions that described how the disability benefit of an owner-employee was to be calculated. The Fourth Circuit Court of Appeals affirmed the ruling of the District Court and upheld Principal’s interpretation of its plan as a reasonable exercise of its discretionary authority to interpret plan terms. Judge Floyd dissented.

The Fourth Circuit reversed the district court’s ruling in favor of the defendant’s ERISA disability plan. The plan hired two pulmonologists to consider whether the claimant was disabled from asthma, a condition which the claimant’s own physician conceded did not prevent her from working. The reviewing pulmonologists failed to consider whether the claimant was disabled by a combination of her other health conditions, including anxiety and depression, skin lesions and arthritis.

District Court

The plaintiff suffered from chronic fatigue syndrome and fibromyalgia, which limited her to half-time work in her position as an administrative assistant. The district court ruled that the employer’s disability insurance policy failed to reserve discretionary authority to Prudential, the claims administrator, citing Woods v. Prudential Insurance Co. of America, 528 F.3d 320 (4th Cir. 2008) and other cases. The court then reviewed the evidence under the de novo standard of review and found that the plaintiff was entitled to benefits.

The plaintiff ceased working for IBM in 2001 after she was exposed to toxic mold following a flood at her workplace. The plaintiff’s physicians differed as to whether the cause of her disability was a physical or mental illness. However, all of the treating physicians and one of MetLife’s reviewing physicians agreed that the plaintiff actually suffered from the symptoms she claimed. The district court held that the plaintiff had satisfied her burden of submitting evidence that she was disabled.

In this case there was no dispute that the plaintiff suffered from relapsing/remitting multiple sclerosis. MetLife reevaluated the plaintiff’s medical records while her symptoms were in relative remission. According to the court, “MetLife’s decision simply came down to a permissible judgment call between conflicting medical opinions. Given the differing conclusions of [the plaintiff’s] treating physicians along with those of [MetLife’s physicians], MetLife’s denial of long-term disability benefits was reasonable and not an abuse of discretion.” The Magistrate Judge therefore recommended that the district court grant MetLife’s motion for summary judgment.

The plaintiff’s evidence showed that she suffered from a number of medical problems, including severe depression, cognitive impairments, basilar artery migraines, coronary artery disease, hypercholesterolemia, and multiple neurological symptoms. The district court held that Nortel failed to provide the plaintiff a full and fair review of her claim and remanded the case to Nortel for an independent review of the claimant’s file.

In this case, the court held that the de novo standard of review applied to the decision by General Electric’s plan administrator to deny the plaintiff’s claim for benefits for disability due to mental illness. The court denied both parties’ motions for summary judgment, stating that fact questions remained as to whether the plaintiff was “totally disabled” by his mental condition.

The plaintiff’s evidence showed that his cognitive problems commenced following a hospitalization for pneumonia, during which he experienced severe hypoxemic respiratory failure and was placed on mechanical ventilation for a time. The court ruled that the plaintiff had the right to file suit after Fortis failed to decide his appeal within the time limits allowed by the regulations. After this ruling, Fortis conceded that the plaintiff was entitled to benefits.

The plaintiff, a small business owner, sued the insurance agent and the insurer, UnumProvident Corporation, in state court to recover disability benefits under an individual disability insurance policy. The defendants removed the case to federal court, alleging that the claim was governed by ERISA. The court ruled that the claim was not covered by ERISA under the “safe harbor” contained in the Department of Labor’s regulations.