Posted on Fri, Feb 03, 2012 @ 01:27 PM
Holders of long term disability policies often face difficulties in receiving payments for disabilities they claim, if not during the initial claim process, then during a periodic review. This is true for Austin-area residents, as well. Austin attorney Lonnie Roach, of Bemis, Roach & Reed, has successfully helped several residents, with different injuries and disability insurance companies, in the cities and towns around Austin fight a denial of their claims.
A Hutto client had a right rotator cuff rupture followed by a right bicep tendon rupture. She experienced significant limitation of motion, weakness and pain. Her physician determined that she could not return to her occupation. She continued to have significant restrictions to her right upper extremity, including no lifting over five pounds, no repetitive motion, no reaching above the horizontal position, and no lifting above the level of the waist with the right arm. She was expected to require repeat surgery after conservative treatment options were exhausted. Lincoln Financial denied her LTD claim, but Bemis, Roach & Reed fought the denial and got it reversed.
Another client, in San Marcos, had a progressive neurogenic disease. This disease caused wasting syndrome of her left arm and deltoid triceps and biceps groups. Our client also had EMG-confirmed neurogenic atrophy of her bilateral lower extremities and wasting in those extremities. She had a surgically inserted pain pump which dispensed a pain medication 100 times as powerful as morphine, and further required narcotic patches to attempt to control her pain. She required a wheelchair to move any significant distances and was eventually confined to an assisted living center. She was found to be totally disabled from any gainful activity by the Social Security Administration. Prudential wrongfully denied her LTD claim. We got her benefits reinstated.
The denial letter for a Taylor client listed a variety of cardiac issues and concluded that the client was not precluded from performing sedentary labor due to those issues. Her claim for disability was not based on a cardiac condition, however. After her cardiac surgery, she suffered an intracerebral hemorrhage which led to massive bleeding in her brain. According to her neurosurgeon, the client suffered from a class 4-severe physical impairment as well as a class 4-severe mental impairment. She suffered from an inability to use and understand spoken language and short term memory loss. This was due to brain damage which had been objectively documented by MRI and CT scans. Although she attempted to return to work, she was terminated because her cognitive deficits rendered her unable to perform her job. As a result of her brain injury, she was determined to be totally disabled by the Social Security Administration. Her Long Term Disability insurer, Lincoln Financial, denied her claim, however. Bemis, Roach & Reed handled her appeal and was successful in getting her benefits restored.
A Round Rock Sales Support Analyst for a large computer company suffered a complete rupture of her rotator cuff and other injuries after a fall. She was awarded SSDI and was receiving LTD benefits. Unum denied benefits after three years. Bemis, Roach & Reed got her a settlement.
Another Round Rock client suffered from degenerative disc disease for over 28 years. She had undergone 18 surgeries to attempt to address her condition and was only able to function due to daily narcotic medication and a surgically implanted morphine pump. Both her orthopedic surgeon and pain management doctors had stated she was totally disabled. Based on her medical records, it does not appear that The Hartford consulted with an orthopedic surgeon or pain management specialist in making its benefit decision to deny her claim. The Social Security Administration had awarded her SSDI based on full disability. The Hartford attempted to settle the remainder of the client’s claim for a single lump-sum payment. It was only after the client rejected The Hartford’s settlement offer that she was put under video surveillance and ultimately denied. We challenged the unfair denial and got her a settlement.
Regardless of the cause of your disability or where in Texas you live, if an insurance company has wrongly denied your claim, call Bemis, Roach & Reed. We may very well be able to help you.
Posted on Fri, Jan 27, 2012 @ 12:09 PM
Austin attorney Lonnie Roach, of Bemis, Roach & Reed, has been able to assist many disabled residents of the Cedar Park / Leander area. These clients have fought to receive benefits due them from their long term disability (LTD) policies, and Mr. Roach as helped them win this fight.
One Cedar Park client had been found to be totally disabled by the Social Security Administration due to his bipolar disorder. MetLife had previously recognized that our client was totally disabled by this condition, which had failed to respond to numerous medication trials. His treating psychiatrist stated that he was "incapable of performing his former job, or any regular employment that involves working under stressful conditions, due to the severity of his mental illness." MetLife eventually denied his claim, but Bemis, Roach & Reed was able to get his benefits reinstated.
Another client suffered from lateral epicondylitis. She was originally awarded LTD by Unum because she could not return to gainful employment as defined by Unum’s LTD policy. Her benefits were denied then reinstated several times over 15 years, then denied again without any significant change in her condition. We took up her case and got Unum to settle.
A Leander man with severe obstructive sleep apnea unsuccessfully underwent surgery in an attempt to correct the condition, which caused him to develop uncontrolled hypertension. In November, 2008, his sleep medicine specialist certified that he had a class 4 physical impairment. The physician determined that, in his current condition, the client was unable to perform any occupation for which he was qualified. This Board Certified Sleep Medicine Specialist certified him as totally disabled, calling the disability “permanent” and a “life-long disability.” The Social Security Administration determined him to be totally disabled under its standards. Despite these previous statements and determinations, Sedgwick’s reviewing physician, who had a questionable past and weak qualifications, generated a report that resulted in our client’s LTD denial. We fought the denial and were able to get our client’s benefits reinstated.
A Cedar Park client suffered a herniated disc. Surgery was not successful. He required narcotic pain management which was, in and of itself, disabling. Total disc replacement surgery was recommended, but was only partially successful. CIGNA based its denial of benefits on an incorrect job description which indicated that the client's profession was sedentary when it was actually highly active and dangerous. Bemis, Roach & Reed filed an appeal and subsequently obtained a settlement.
A Leander client brought Bemis, Roach & Reed on to assist in the appeal of both short and long term disability claims. Aetna stated it did not consider the Social Security Administration’s finding of total disability because it did not review Social Security’s file. In the SSA's Award letter to the client, it determined that the client's osteoarthritis and associated conditions rendered her presumptively disabled under its guidelines. She underwent a Posterior Lumbar Interbody Fusion surgery due to her unremitting pain. Aetna's psychiatrist found that the client was significantly impaired due to pain secondary to her avascular necrosis, and pain medication. She had been adjudged totally disabled by the Social Security Administration. We were successful in her appeal and got her benefits reinstated.
In her doctor's opinion, a Leander, Texas client needed to be on permanent disability. The physician believed it a matter of time until the client would need further surgical intervention on her cervical spine. CIGNA took its reviewing physician’s opinion over that of our client’s primary physician even though the reviewing physician never examined the client. Cigna ended up offering a settlement.
If you are a Cedar Park or Leander resident, or are from anywhere in Texas, and have recently had your LTD claim denied, contact Lonnie Roach to find out how he can assist you.
Posted on Fri, Jan 20, 2012 @ 12:25 PM
Lonnie Roach, of Bemis, Roach & Reed, handles LTD cases for clients across the State of Texas suffering from a wide range of disabilities. These clients are fighting many different insurance companies to get the benefits they qualify for. Here are the stories of a few Austin residents who benefitted from our knowledgeable assistance.
An Austin physician was diagnosed with Ankylosing Spondylitis, a chronic condition that caused him intractable low back pain. Ankylosing Spondylitis has no known cure and, in our client’s case, required significant amounts of narcotic pain medication in order to attempt to control the associated pain. Even The Standard’s physician reviewer acknowledged that work was not recommended for this patient. His insurance company was not convinced, however, and denied his claim. We fought The Standard’s unreasonable denial and the client’s benefits were reinstated.
A Unum patient suffered from severe carpal tunnel syndrome with Martin Gruber anomaly. She had deformity to median nerves and permanent impairment to her bilateral hands of 45%. Her physicians permanently restricted her to four hours of work per day, and her employer determined she was not capable of continuing her occupation in a full time capacity and would therefore be terminated. Bemis, Roach & Reed filed a federal lawsuit to overturn the denial and was able to obtain a settlement for her.
A Cigna client suffered from major depressive disorder and was hospitalized due to job-related stress. Benefits were initially awarded, then denied because Cigna claimed she had been released to return to work, yet had not done so; however, her physician, though he had planned to, never released her to return to work. Our client had, in fact, suffered a relapse and was under the continual care of her physician. We fought the denial and won a reinstatement of her benefits.
According to the medical records, one of our clients had been certified as totally disabled due to bi-lateral peripheral neuropathy from Agent Orange exposure. Despite confirmation by one of the client's treating physicians, a review for Jefferson Pilot Insurance, performed by a nurse, determined his condition was not severe enough to merit short term or long term disability. We appealed his denial and won him a settlement.
Another client had been continuously disabled for more than six years. The Social Security Administration and the treating physician had found her to be totally disabled. She suffered from multiple co-morbid conditions that ruled out employment of any type. In addition to the serious and debilitating medical conditions our client endured, she required extended release opiates which rendered her unable to safely operate a motor vehicle. According to her gastroenterologist, she had been hospitalized five times over two years so that she could be treated with intravenous Phenergan, which she also took frequently at home. Although it helped with the daily nausea she suffered from, it had a sedating effect that further impaired her ability to work. We appealed MetLife’s denial and got benefits reinstated.
If you live in the Austin area, Dallas-Fort Worth, Houston, San Antonio, or anywhere in the State of Texas, and your LTD claim has been denied, contact Bemis, Roach & Reed to find out how we can assist you.
Posted on Fri, Jan 13, 2012 @ 01:30 PM
A college professor in north Texas contacted Bemis, Roach & Reed to assist in challenging the denial of long term disability (LTD) benefits through Fort Dearborn Life Insurance Company. At the time we were contacted, the client had already initiated an appeal of the Fort Dearborn denial by requesting a review from the Employee Retirement System of Texas (ERS). The claim was set for hearing before an administrative law judge (ALJ) with the State Office of Administrative Hearings in Austin, Texas.
The college professor suffered from fibromyalgia. The disease had progressed to the point that work was no longer possible due to constant pain and fatigue. Fort Dearborn denied the claim when it was filed.
Bemis, Roach & Reed accepted the representation and began to litigate the case. We arranged for our client to attend a functional capacity evaluation (FCE). The FCE supported our contention that our client could no longer work as a college professor. We also developed medical testimony from the client’s treating physicians.
The case resolved to the satisfaction of all parties by confidential settlement prior to the ALJ hearing.
If you are an employee of an educational institution or if you are an employee of the State of Texas and have been denied disability benefits, contact the long term disability attorneys at Bemis, Roach & Reed. We are an Austin based law firm and can assist you with your claim.
Posted on Fri, Jan 06, 2012 @ 04:41 PM
Very few people plan on becoming disabled. However, 14% of Texans and 20% of all Americans suffer from some level of disability. If you have been active in the workforce, but have become disabled to the point of being incapable of work, you might be eligible for Social Security Disability Income or Long Term Disability Benefits. Many are eligible for both, but the similarities and differences between the two benefit options can be hard to get straight. Here are the basics for both types of disability assistance.
Social Security Disability Income
- Public disability benefit tied to your Social Security benefits.
- Administered and governed by the Social Security Administration, a Federal entity.
- Available to any resident with a social security number who has at least 20 work credits with the Social Security system in the 10 years preceding the qualifying event.
- Benefit amount is based on previous contributions.
- You can receive benefits if you have a disability which has lasted, or is expected to last, 12 months or more.
- Once awarded SSDI, you are paid retroactively for the time period since your sixth month of disability. However, back pay is retroactive for no more than 12 months prior to your filing date, so don’t wait to file.
- Benefit amount is unaffected by private disability benefits, but is affected by any other public disability payouts, such as Workers’ Compensation. You cannot receive an amount equal to more than 80% of your salary at the time of qualifying incident.
- You may be able to work and earn limited amounts and still receive SSDI.
Long Term Disability
- Private disability insurance provided through an individual or group policy, oftentimes as an employer-provided benefit.
- Administered by a private insurance company or administrator and governed by ERISA laws issued by the Federal Government.
- Benefit amount is typically 50% to 70% of your salary when you were last able to work.
- Most policies contain an elimination period that must be met before benefits are payable. These elimination periods typically vary from 30 to 180 days.
- Benefit amount is often reduced by other disability benefits, including SSDI. If you have been receiving LTD benefits and are awarded SSDI (including retroactive back-pay), your LTD provider will likely decrease your monthly benefit by the amount of your SSDI benefit. It will also likely request overpayment reimbursement for the retroactive time period (effectively capping your total disability benefit amount to the maximum provided by your policy).
- Some policies provide benefits for partial disability allowing limited work.
If you live in Dallas, Houston, San Antonio, Austin, or anywhere across Texas and have applied for either SSDI or LTD benefits but have been denied, contact lawyers Lloyd Bemis, Lonnie Roach, or Greg Reed of Bemis, Roach & Reed. We can take the lead on your appeal process and increase your chances of getting the benefits you deserve.
Posted on Fri, Dec 30, 2011 @ 10:58 AM
While a lawyer with Bemis, Roach & Reed, I've represented clients in their battles to access their Long Term Disability benefits and seen several reasons used to deny claims. Knowing the common reasons for denial before you've filed a claim can help you avoid potential road blocks to receiving your benefits.
Pre-existing condition – Like health insurance, Long Term Disability (LTD) insurance often contains exclusions for pre-existing conditions, or conditions for which you received treatment three to six months prior to your claim. These exclusions can last up to 24 months.
Lack of objective medical findings – Your doctor’s opinion that you are disabled must be supported by medical evidence (office notes, imaging studies, blood tests, etc.) and must not be inconsistent with substantial medical evidence in your administrative record. If there have been no lab tests, x-rays or other objective medical documentation to support an opinion of disability, your claim is more likely to be denied.
Can still perform your job – The inability to perform your own job is not the typical standard used. Most insurers look to how your “occupation” is performed in the national economy. This gives them plenty of leeway to argue that, even though you may not be able to perform your regular job, you can still perform your “occupation”.
Self-reported symptoms (migraines / fatigue) – Your claim has a higher likelihood of being denied if the condition by which you are disabled, such as migraines or fibromyalgia, relies heavily on subjective evidence like self-reported pain or fatigue. Typically, there are no lab tests or x-rays that will verify these conditions, so the task of proving your disability becomes much more difficult, though not impossible.
Not pursuing proper medical care / treatment – In order to be able to provide objective medical evidence for your administrative record (on which your claim is based), you must seek appropriate medical care. Without such care and the findings it generates, the claim reviewer has no way to verify your claim.
Failure to meet definition of disability – Your LTD policy includes a definition of “disability.” These definitions vary considerably from policy to policy. It’s entirely possible your condition satisfies the definition under one policy, but not under another.
Engaging in an act listed as a policy exclusion – Disabilities resulting from acts such as commissions of crimes or self-harm, like a suicide attempt or substance abuse, are often included in a LTD policy’s list of exclusions. Any claim based on actions on this list will be denied.
Failure to meet contractual eligibility requirements – Contractual eligibility requirements in your LTD policy typically include things like a minimum period of employment at the company that offered the policy before becoming eligible for benefits. If you don’t satisfy these requirements, your claim will be denied.
Misrepresentation on insurance application – Intentionally providing incorrect information on your policy application, which often includes questions about your health and medical history, will frequently result in a denial of your claim and your policy being terminated.
Capriciousness of LTD insurance provider – Even avoiding all of these claim pitfalls, your LTD insurance provider might deny your legitimate claim. This is because most LTD insurers decide your claim while under a conflict of interest. If they decide you deserve benefits, they must pay them out of their own pocket. It’s not surprising, therefore, that these companies often err on the side of denying. If you have been denied, contact us. We have been able to help hundreds of clients overturn wrongful denials.
Posted on Thu, Sep 15, 2011 @ 01:05 PM
Mr. Greg Reed, of Bemis, Roach & Reed, has been named to the Texas Super Lawyers list as one of the top attorneys in Texas for 2011. No more than 5 percent of the lawyers in the state are selected by Super Lawyers.
Mr. Reed, along with his partners Lloyd E. Bemis, III and Lonnie Roach, founded Bemis, Roach & Reed in late 1993. In the nearly 20 years since its formation, Bemis, Roach & Reed has successfully represented thousands of clients against big business, big insurance and big government.
Mr. Reed has a busy litigation practice in both Federal and State court. He represents clients in disability cases and in serious personal injury cases. His disability practice includes representing individuals who have been denied private disability insurance benefits and also individuals who have been denied public disability benefits such as Social Security and State of Texas ERS and TRS benefits.
Bemis, Roach & Reed is one of the very few firms in the state of Texas that handles every aspect of your disability case. They look forward to being your law firm.
Super Lawyers, a Thomson Reuters business, is a rating service of outstanding lawyers from more than 70 practice areas who have attained a high degree of peer recognition and professional achievement. The annual selections are made using a rigorous multi-phased process that includes a statewide survey of lawyers, an independent research evaluation of candidates, and peer reviews by practice area.
The Super Lawyers lists are published nationwide in Super Lawyers magazines and in leading city and regional magazines across the country. Super Lawyers magazines also feature editorial profiles of attorneys who embody excellence in the practices of law. For more information about Super Lawyers, go to superlawyers.com. The first Super Lawyers list was published in 1991, and by 2009, the rating service had expanded nationwide. In February 2010 Super Lawyers was acquired by Thomson Reuters, the world’s leading source of intelligent information for business and professionals.
THE SUPER LAWYERS SELECTION PROCESS
The transparent, multiphase process includes the following steps:
• A statewide survey of lawyers
• Independent research to identify outstanding lawyers
• Evaluation of candidates based on 12 indicators of peer recognition
and professional achievement
• A blue ribbon panel review by practice area
• A discipline check of each candidate
Posted on Tue, Apr 05, 2011 @ 03:15 PM
COBRA is the acronym for the Consolidated Omnibus Budget Reconciliation Act, which was signed into law in 1986. The law amends the Employee Retirement Income Security Act (ERISA) so that employees can extend their health care benefits when they would otherwise lose them due to a job action. In most instances, the job action means termination of employment, although loss of health care benefits can also result from a cutback in hours worked. The termination can be voluntary or involuntary so long as the termination was not for cause. Not all employers are required to offer COBRA coverage. Companies with less than 20 employees are exempted. If your company offers COBRA coverage, you may be allowed to stay on your company’s health plan for up to 29 months.
This blog is titled COBRA TRAP because many disabled individuals end up with only 18 months in COBRA coverage rather than 29 months. If you file for Social Security Disability (SSDI) during the initial 18 months of COBRA coverage and are granted benefits during that 18 months, you will, in certain circumstances, be entitled to another 11 months on your employer’s health plan. If you file for SSDI but do not receive your Notice of Award letter until after the initial 18 months, COBRA cannot be extended. Additionally, most plans require that the Plan Administrator be informed of the successful SSDI claim within 60 days of receipt of the Notice of Award letter.
For disabled individuals on COBRA, it is extremely important to file for SSDI without delay. The average processing time for a SSDI claim is over 300 days. You must receive your Notice of Award during the first 18 months of COBRA coverage and then forward it to the Plan Administrator within 60 days. Extending the eligibility by 11 months is crucial because SSDI recipients are not eligible for Medicare for 29 months after they are determined to be disabled. You can see from these rules that you must be diligent. If your COBRA coverage ends at 18 months, you may be forced to go without health care coverage for 11 months while waiting for Medicare to start.
COBRA is not welfare. During the first 18 months of coverage, you can be charged up to 102% of the total cost of the health care premium. That means the combined portions paid by the employer and the employee. If the benefit is extended, the COBRA premium can be as high as 150% of the combined portions paid by the employer and the employee. That is a lot in premiums, but most folks cannot afford to be without coverage.
Don’t get caught without coverage. If you are on COBRA and are disabled, you need to file for SSDI. You need to contact a disability attorney to help you with your case.
| Visit Greg Reed’s page to arrange your Free Long Term Disability or Social Security Disability Consultation today. |
Posted on Tue, Mar 29, 2011 @ 10:43 AM
Teachers Face Massive Layoffs
If you are a teacher in Texas, you have a target on your chest. The State of Texas is facing a budget deficit estimated at 27 billion dollars. Unfortunately for Texas teachers, Governor Perry has decided that our educational system is “bloated” and can bear a substantial amount of the burden for trimming the deficit. Proposals are circulating in the Texas legislature which, if passed, would cause public education to be underfunded by approximately 10 billion dollars. Texas State Teachers Association President Rita Haecker states, “Texas’ classrooms already are under-funded. This bill would cost thousands of school employees their jobs, cram tens of thousands of kids into overcrowded classrooms, close neighborhood schools and sacrifice Texas’ future for political expediency.”
Some of the teachers facing layoffs are suffering from illnesses and injuries that make it extremely difficult for them to perform their jobs. They have been hanging on in an attempt to continue in the profession they love. If those individuals lose their jobs in this budget crisis, how are they to find a replacement job in the state economy? The bottom line is that most will not be able to find another job. Keeping a job while disabled is much easier than finding a job while disabled.
There may be options. Teachers with a disability may qualify for benefits with the Teacher Retirement System of Texas (TRS). In order to qualify, you must show that you have a physical or mental condition that disables you from performing your duties. You must also show that your condition is likely to be permanent. The amount of your benefit is based on your seniority and on your pay. If you have more than ten years of service, you may be able to select an annuity that will pay you a specified amount; the amount is not reduced based on your early retirement age. With less than ten years of service, the benefits are more limited. A full description of the benefits are here.
Another option may be to file for disability under a private disability insurance plan. Nearly all TRS members are given the option to purchase disability insurance through their employer. The policies generally include coverage for both short term and long term disabilities. This differs from disability retirement in several ways. Most importantly, the definition of “disability” in a private policy will be defined by the contract. The TRS definition of disability may well be different. Also, applying for benefits under a private plan does not necessarily mean retirement. Many individuals return to the workplace after using short term disability/long term disability (STD/LTD) benefits. They develop a condition such as a heart attack, cancer or injury, then receive treatment for the condition and recover. Once they recover, they can return to the classroom.
If you are a teacher and have been denied disability retirement by TRS or if you have been denied STD/LTD benefits that you purchased, contact Texas disability attorney Greg Reed. You will receive a free consultation.
In these difficult economic times, knowledge is the key, no matter what Governor Perry thinks.
| Visit Greg Reed’s page to arrange your Free Long Term Disability or Social Security Disability Consultation today. |
Posted on Tue, Jan 18, 2011 @ 10:49 AM
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One major advantage of having both a long term disability practice and a Social Security Disability practice is the synergy created between the two practices. Many clients come to me, Lonnie Roach, to hire me for their Long Term Disability claims when they have been denied and I note they probably qualify for Social Security Disability as well. Similarly, some clients hire us to represent them for their Social Security Disability claim when they have been denied, then find they need help with a long term disability claim under their private or ERISA LTD plan. We have found that in many instances, representing a client for both claims helps achieve a better result than separate representations would have been likely to do.
Recently, one of our cases provided an example. Our client came to us for help with a Long Term Disability claim that had been denied. I noticed that the client likely qualified for Social Security Disability (SSDI) and put her in contact with my partner Greg Reed to help with that claim. The Social Security claim ultimately went to an administrative hearing in which we prevailed. In the meantime, my client’s Long Term Disability appeal had been denied and we were preparing to file a lawsuit. After winning the SSDI claim, however, we changed course and filed another appeal of the Long Term Disability denial including our newly won, fully favorable decision from Social Security. Even though the Long Term Disability appeal period had ended, the carrier reviewed the appeal again and granted it. Our client now receives both the Social Security and Long Term Disability benefits she is entitled to and we did not have to file a lawsuit. Here at Bemis, Roach & Reed, we are always looking out for our clients best interest.
| Have you been denied LTD Benefits? Visit Lonnie Roach’s page to arrange your Free Legal Consultation today. |