WIE Season 3 EP 19 PART 2: What Hartford Disability Insurance Company Did From What a Doctor Said

Welcome back to winning isn't easy. So what did Hartford do when a doctor said that he was hopeful that the policyholder could return to work in six months? I will tell you nothing will stop a disability insurance company from looking for reasons to terminate a long-term disability claim even if the policyholder has been receiving those long-term disability benefits for over 20 years. Now one of the games that disability carriers will play is to cherry pick a doctor's statements and they will also cherry pick the medical records. They'll take these statements out of context to justify a wrongful claim termination and they're going to bet that they're going to win in federal court. So this is a real story. Let me tell you the story of Anthony Carelli who worked as the vice president of Bear Stearns until December of 1999. He was injured in a catastrophic motor vehicle accident and he was left permanently disabled. He underwent many surgeries, he had negative side effects of a doctor prescribed pain medication, he suffered a stroke, he began to suffer from depression and clearly he was disabled. Hartford paid benefits through 2019 and at that point the games began and it began because one of his physicians didn't help him. In 2019 the treating physician Dr. Francis said that he was hopeful that Carelli could return to work in six months if certain treatments and changes in medication proved effective. That's a heck of a lot of ifs, isn't it? But that didn't deter Hartford from terminating his benefits after the change in treatment and medication and it didn't matter that it wasn't successful. They denied his claim and ultimately of course this goes to federal court. Judge Sessions of the United States District Court in Vermont was not impressed with Hartford. Now in my view this case is a classic textbook claims denial. It's textbook 101. One of the basic principles in an ERISA case is that a disability carrier has to justify a claims determination based on a change in medical condition. So what did Hartford do? They seized on comments in the treating physician provider's records and how the provider completed the attending physician statement form or alleged perhaps that there had been some improvement. This is classic textbook claim denial 101 and I think it illustrates why you should be having an experienced ERISA disability attorney monitoring and managing your claim even if it's being paid. Even if it's been paid for 20 years. In this case the medical records continue to document that Carelli suffered from significant pain because of an L3 to L5 fusion of the back. He had limited ability to sit stand and bend at the waist. He had difficulty kneeling and crouching or reaching above his shoulders. The trouble began when Dr. Francis made that note. And again the carrier is going to seize on that. I hate it when a doctor says well if we change the treatment there might be a reassessment of the medical condition if there's been improvement and we're going to try this and try that. There's no problem doing any of that but to predict that potentially there's going to be improvement that just makes for problems. Now Francis was well-intentioned because he was on a lot of medication and we know that physicians are not all that wild about the use of narcotic medication. And so he, Dr. Francis, was trying to address this ongoing use of pain medication to see if there were alternative treatments. But that doesn't mean that you're necessarily going to improve and that you're necessarily going to be able to return to work. And in this particular case after Dr. Francis changed the treatment there wasn't any change in his condition. And Francis said look I think this condition is permanent. Well guess what? Hartford said well we're going to send a letter to Dr. Francis and we're going to ask him whether or not Carelli could engage in sedentary work that involves sitting most of the time but could do a little walking and a little standing for brief periods of time. Dr. Francis didn't do Carelli a favor here. He took the bait and he opined that Carelli could do sedentary work on a full-time basis. He completed an additional attending physician statement form documenting that Carelli could sit, stand, or walk for an hour at a time and could sit for four hours out of an eight-hour day. Now if Carelli had been represented his attorney would have headed this off at the pass and had Francis clarify his opinion and make it clear that Carelli couldn't work or even have Carelli undergo a functional capacity evaluation to document that. Now Hartford said hey we're going to deny this claim because of his notes and Dr. Francis's APS forms. Obviously Carelli appeals and guess what? He had that functional capacity evaluation in January of 2020 and it found that he could only sit for one hour at a time for a total of three to four hours in an eight-hour day. He could only stand for 10 minutes at a time and he could only do that for a total of one hour in an eight-hour day. He only had the stamina for two to three hours of work per day and during that functional capacity evaluation Carelli's pain level was between a five and a seven. What does Hartford do? Well Hartford attacks the functional capacity evaluation and it was critical of the FCE provider's evaluation methods. Carelli had two failing scores on the grip strength test and Hartford noted that that consistency of effort was poor and therefore the results of the functional capacity evaluation wasn't valid. They argued that the FCE provider should have done a third test of validity and that the FCE results were based on Carelli's self-reports which were not validity tested. Now it also should be noted that the APS forms and the FCE documented restrictions and limitations that were really less than sedentary. Fortunately Dr. Francis signed off on the January 2020 FCE and of course Hartford was not going to change its opinion so they retained a medical reviewer who disagreed with the FCE and agreed with Dr. Francis's original opinion on October of 2018 that Carelli could do a sedentary job on a full-time basis. You can see how the doctor really screwed this case up. So what did the federal judge do? Well this is the case of Carelli versus Hartford Life at Santa Vermont and as I noted the judge closely reviewed the medical records and realized that Dr. Francis had revoked his opinion that Carelli might improve and had informed Hartford that Carelli was still disabled from all professions despite Dr. Francis's earlier optimism and the court rejected fortunately Hartford's arguments about the FCE. They noted that while the validity testing and the objective measures were desirable that the court couldn't and shouldn't dismiss subjective self-reporting as presumptively invalid and in a dig at Hartford the court noted that if Hartford was using the grip test to suggest that the FCE provider's methods were flawed or that Carelli wasn't credible or both those attacks were thin like thin ice. The FCE report reflected a thorough examination that was performed over four to five hours and there were a number of a variety of assessment tools and the consistency of effort was evaluated by several means and so the court said I'm not buying this and the court also looked at Carelli's credibility. The judge looked at the consistency of the reporting for over 20 years and the judge said look there's no malingering of suggestion of malingering in any of these records and the court therefore concluded that Hartford abused its discretion. Carelli's medical history clearly established that since the car accident his treating physicians had all maintained that he was unable to perform full-time work and that his condition was permanent. The records didn't show any evidence of any change in Carelli's medical condition to justify a claims denial despite Dr. Francis's wishful thinking. Fortunately the judge reversed the denial and awarded benefits but it took years years to correct what could have been corrected if Carelli only had an ERISA disability attorney on retainer monitoring his forms and the medical records. Got it? Let's take a break. Are you a professional with questions about your individual disability policy? You need the Disability Insurance Claim Survival Guide for Professionals. This book gives you a comprehensive understanding of your disability policy with tips and to-dos regarding your disability application that will assist you in submitting a winning disability application. This is one you won't want to miss. For the next 24 hours we are giving away free copies of the Disability Insurance Claim Survival Guide for Professionals. Order yours today at disabilityclaimsforprofessionals.com