Florida Insurance Law Blog : Florida Insurance Lawyer & Attorney : Mark Nation Law Firm : Orlando, Longwood, Gainesville

My client took out a short term disability policy in December of 2010. He then suffered a stroke in May of this year. His short term disability carrier denied the claim, asserting that the stroke was a preexisting condition. 

You won’t be surprised to hear that I filed a lawsuit against the STD carrier for breach of contract. I can’t wait to see how they prove that a stroke that occurred in May 2011, preexisted an insurance policy taken out in December 2010. 

As with most of my insurance cases, if I am successful, the insurance company will be required to pay my hourly fees and costs, and if I lose, I’ll work for free. 

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You are much more likely to become disabled during your work life than to die during your work life. Thus, disability insurance is very important to protect you and your family from financial ruin in the event of a disability. But, what happens when you insurance company denies your disability claim?

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Recently, we prevailed in federal court on a contract interpretation issue under an ERISA short term disability insurance policy. 

Due to an illness, our client could not perform some of the essential duties of her job. She could perform some of her duties, she just couldn’t perform them all. Our client filed a claim for STD benefits under her ERISA plan. The insurance company denied the claim, asserting that she could still perform some of the material duties of her job, and therefore she did not meet the definition of “disabled” under the insurance policy.

We filed suit in federal court. On summary judgment, the Court found agreed that an insured could be entitled to disability benefits if she could show that she was disabled from only one of the essential duties of her occupation. Plaintiff cited Lain v. UNUM Life Insurance Company of America, 279 F.3d 337 (5th Cir. 2002), abrogation recognized on other grounds, Holland v. International Paper Co. Retirement Plan, 576 F.3d 240 (5th Cir. 2009) in support of her position.

The AT&T Plan at issue defined disability as follows:

“Total Disability” or “Totally Disabled” for short-term disability means that because of Illness or Injury, you are unable to perform all of the essential functions of your job or another available job assigned by your Participating Company with the same full-time or part-time classification for which you are qualified.

The Court found the phrase “all of the essential functions” ambiguous. The Court rejected the Defendants’ argument that if plaintiff could do one of the essential duties of her job, then she was not disabled. Instead, the Court found that if, for example, there were 10 material duties of her occupation, if she was unable to do even one of those duties, then she would be disabled as defined by the Plan.

Litigation continues.  In cases like this we, represent the policy holder on a contingency fee basis.  There are no fees or costs unless we win, and if we do win we will attempt to force the insurance company or plan administrator to pay our fees and costs under 29 U.S.C. Section 1132(g). 

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My client is a veterinarian who became disabled due to cancer and the subsequent grueling treatments.  Her disability insurance carrier is New York Life. 

Although New York Life has not technically denied the claim they might as well have.  Instead of quickly processing the claim, their claims administrator has repeatedly requested the same information time and again.  Once they finally acknowledge that they have the information they then ask for information that that they should have requested at the beginning of the claim if it was important.  They have also repeatedly asked for information that simply does not exist.  When my client explains that the information does not exist, they ask for it again.  In the meantime, my client suffers not only with her ongoing medical conditions, but she is in desperate need of her disability benefits. 

As with most of my insurance cases, if I win this case, the insurance company must pay my fees and costs, and if I lose, I'll work for free.

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The Nation Law Firm recently filed an administrative appeal for certain disability benefits under the terms of the Harris Corporation Disability Plan. Plaintiff was successful in this appeal and benefits were reinstated.

The Nation Law Firm recently handled an administrative appeal under an ERISA plan against Principal Life Insurance Company. Plaintiff prevailed in the appeal and benefits were reinstated.

The Nation Law Firm recently handled an administrative appeal on behalf of a claimant. Benefits were sought from the Life Insurance Company of North America. Plaintiff prevailed and benefits were reinstated.

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We recently filed a lawsuit seeking certain short term disability benefits under the terms of the Federal Express Short Term Disability Plan. Litigation continues.

 We also recently filed suit seeking short term disability benefits under the terms of the Blue Cross and Blue Shield of Florida Short Term Disability Plan. Plaintiff was an employee of Blue Cross and Blue Shield of Florida. Litigation continues.

 In another case, we filed suit seeking long term disability benefits under an ERISA governed plan. Suit was filed against Connecticut General Life Insurance Company.

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