Diseases - What You Must Know About Getting Benefits for Them, What Carriers Don’t Understand about Them, and How Carriers Will Wrongfully Deny Claims for Them

Welcome to Season 4, Episode 40 of Winning Isn't Easy. In this episode, we'll dive into the complicated topic of "Diseases."

Host Nancy L. Cavey, a seasoned attorney with extensive experience in disability claims, explores diseases in a general sense, and how they relate to disability claims. While Winning Isn't Easy has explored of a number of diseases in disease-specific episodes, we've never dedicated an episode to the topic as a whole. In this episode, Nancy L. Cavey will be walking through the major components of a disability claim, describing how diseases interact with each via example, including how to get benefits for a disease, what carriers don't understand about diseases, and how carriers will wrongfully deny claims for diseases.

In this episode, we'll cover the following topics:

1 - What Every ERISA Disability Policyholder or Plan Beneficiary Must Know about Getting Disability Benefits for Graves’ Disease

2 - Extra Flexible Joints, Chronic Pain, and Stretchy Skin – What ERISA Disability Carriers Don’t Get about Ehlers-Danlos Syndrome

3 - Reliance Standard Wrongfully Denies Claim of Nurse Anesthetist with Lyme Disease and Breast Cancer

Whether you're a claimant, or simply seeking valuable insights into the disability claims landscape, this episode provides essential guidance to help you succeed in your journey. Don't miss it.


Resources Mentioned In This Episode:

LINK TO ROBBED OF YOUR PEACE OF MIND: https://caveylaw.com/get-free-reports/get-disability-book/

LINK TO THE DISABILITY INSURANCE CLAIM SURVIVAL GUIDE FOR PROFESSIONALS: https://caveylaw.com/get-free-reports/disability-insurance-claim-survival-guide-professionals/

FREE CONSULT LINK: https://caveylaw.com/contact-us/


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Transcript

Nancy Cavey [00:00:11]:
 Welcome to Winning Isn't Easy. I'm Nancy Cavey, a national ERISA and individual disability attorney. Before we get started, I've got to give a legal disclaimer. This podcast is not legal advice. The Florida Bar association says I've got to say that. So now that I've done that, nothing will ever prevent me from giving you an easy to understand overview of the disability insurance world, the games that disability carriers play, and what you need to know to get the disability benefits you deserve. Now, in the course of this podcast, over the many years we've been doing this, we've covered a lot of individual diseases. Today, I'm going to dedicate a whole episode to discussing diseases and how disability carriers or plans will use disability tools, if you will, in their denial toolbox to deny or terminate benefits.
 
 Nancy Cavey [00:01:04]:
 While I'm going to cover some specific diseases, I want you to understand that the games that they play are generally games that they'll play in every type of disease claim. So while I may not be talking about your specific disease, the games will generally be the same. I want you to understand what you need to know about getting the benefits that you deserve, what carriers generally don't understand about the diseases, and how they'll often reach into their toolbox of denial tools and pull out some tools to deny or terminate your benefits. Okay, so I'm going to talk about three things. First, whatever your risk of disability policyholder or plan beneficiary has to know about getting disability benefits for Graves disease, what disability carriers don't get about ehlers, Danlos syndrome, extra flexible joints, chronic pain and stretchy skin. And lastly, I'm going to talk about how Reliance Standard used one of their tools in their toolbox to wrongfully deny a claim of a nurse, anesthetist with Lyme disease and breast cancer. Got it. Let's take a break.
 
 Speaker B [00:02:11]:
 Been robbed of your peace of mind by your disability insurance carrier, you owe it to yourself to get a copy of Robbed of your peace of Mind, which provides you with everything you need to know about the long term disability claims process. Request your free copy of the book@kvlaw.com today.
 
 Nancy Cavey [00:02:36]:
 Welcome back to Winning Isn't Easy. What every ERISA disability policyholder or plan beneficiary has to know about getting disability benefits for Graves disease. Now, as I suggested, many disability insurance carriers or plans use the same denial tools that they'll whip out of their toolbox to deny or terminate benefits. And I'm going to talk about Graves disease and illustrate to you some of the tools that Disability carriers will use not only in Graves Disease claims, but disease claims generally. Graves disease is an autoimmune disorder that causes your immune system to attack your thyroid gland. In Graves Disease, your body is producing more thyroid hormones than necessary and that in turn will speed up many of your body's functions. As a result of Graves Disease, you might have weight loss, muscle weakness, fast or irregular heartbeat, difficulty sleeping, fatigue, and difficulty tolerating heat. Now, having represented folks with Graves Disease, I know that these problems can make it difficult, if not impossible, to perform not only their own occupation, but any occupation.
 
 Nancy Cavey [00:03:48]:
 Before you stop work and apply for benefits as a result of any disease, including Graves Disease, you should be doing several things. First, you should get a copy of the policy of the plan, and secondly, you should get a copy of your medical records. You want to understand your policy or plan in terms of the definition of disability, the definition of occupation, what it is you need to prove your claim in terms of proof how long benefits are going to be paid, particularly knowing whether or not there is any limitation called a subjective medical condition limitation provision that will limit benefits to just two years. More importantly, I wouldn't say that just as important, you should read your medical records cover to cover, because medical proof is key regardless of the nature of the disease. I find that many ERISA disability claims are denied because of the lack of current diagnosis, a lack of objective medical findings, or because the carrier or plan simply didn't think that your condition is disabling, even in view of complications. So what are the disabling complications of Graves Disease that in and of themselves could give rise to an ERISA disability claim? Just like many diseases, there are complications and in the case of Graves disease, those can include stroke, heart failure or other heart related problems, osteoporosis, skin issues caused by Graves disease, and visual issues caused by Graves disease. Now, what I find is that it's not uncommon that people will have both skin and visual problems as a result of Graves Disease that just aren't appreciated by the disability carrier plan. Those skin issues can cause reddened, inflamed, itchy and thickened skin that can impact your ankles, your feet, your knees, your elbows, elbows, your upper back, your neck, your forehead and your arms.
 
 Nancy Cavey [00:05:44]:
 The visual issues obviously can cause redness, inflammation, swelling of the eyelids, sensitivity to light, double vision, decreased eye movement or eyelid movement, incomplete closure of the eye, and even compression of the optic nerve. Any one of these complications that I mentioned, be it as a result of a stroke, osteoporosis, skin or visual issues can impact your ability to perform your own or any occupation. It is crucial that your medical records are documenting not only the underlying diagnosis for your disease and the objective basis of that in terms of physical exam findings and testing, but that your records are documenting your symptoms, the progression of the symptoms, and how those symptoms impact your ability to do your own or any occupation as those terms are defined. Think about the symptoms of your disease, be it Graves disease or any other disease. I have my clients take out a piece of paper. On the one side, they write down the symptoms, they draw a line across this piece of paper, and then they write down the impact that those symptoms have on their functionality. So it might be because of the visual issues, you can't be in a room with bright light or you can't even look at a computer. It might be that you have difficulties with concentration.
 
 Nancy Cavey [00:07:07]:
 It might be that you have other issues or symptoms that impact your ability to do the material and substantial duties of your own brain occupation. You want to make sure that you are giving this history to your doctor because that history will tell the story of your symptoms, the progression of your symptoms, and why you can't do your own or any occupation duties. Got it? So let's take a break and we're going to come back and talk about Ehlers Danlos Syndrome. Welcome back to Winning Isn't Easy. Extra flexible joints, chronic pain and stretchy skin. What ERISA disability Carriers don't get about Ehlers Danlos Syndrome Ehlers Danlos syndrome was first described in medical literature by a Danish physician, Edouard Ellers, and a French physician, Henri Alexandre Danlos, in the early 20th century. Now, I will tell you that unfortunately, many ERISA disability carriers or plans take a 20th century approach to handling an ERISA disability claim. For Ehlers Danlos, known as EDS, EDS covers 13 genetic connective tissue disorders characterized by hypermobile joints and stretchy, velvety skin.
 
 Nancy Cavey [00:08:41]:
 But there are subtypes of EDs that disability carriers don't appreciate. They kind of lump EDs in a big bucket. There is hypermobile EDs 8 EDs, which involves joint instability, dislocations, joint pain and fatigue. There is brittle cornea syndrome, bcs, where the cornea becomes thin and fragile. There's also periodontal EDS peds, where the tissue that supports your teeth break down. Now, Ehlers Danlos syndrome and its subsets impact the skin, the skeleton and the internal organs. And obviously it can result in an inability to do your own or any occupation. Let's talk about the diagnosis of Ehlers Danlos syndrome.
 
 Nancy Cavey [00:09:27]:
 Unfortunately, many will wait years before the onset of symptoms before getting a correct EDS diagnosis. And it's not because they aren't seeing physicians. It's because doctors don't always get EDs that can play into an ERISA disability carrier or plan's hands. Because disability carriers expect there will be a diagnosis. I find that misdiagnosis, proper diagnosis, be hard because it's commonly associated with other disabling men. And carriers don't understand those, much less EDs. Those disorders can include POTs, digestive disorders, sleep disorders, and anxiety disorders. And when the carriers see all these multiple diagnoses, the adjuster's head just spins.
 
 Nancy Cavey [00:10:19]:
 They don't know what the correct diagnosis is. They don't know what the combination of diagnosis means. They don't know how to evaluate each individually or in combination. And they don't even understand how each individually can be disabling, much less the combination can be disabling. There are very few providers who specialize in the spectrum of these disorders, and hopefully you're being seen at one of the 18 Centers of Excellence in the United States that specialize in eds. Now, that's crucial because disability carriers are always looking for a reason to deny a claim on the basis of no diagnosis or that your symptoms don't neatly fit into the diagnostic criteria and therefore could not possibly be disabling. The longer you go without a diagnosis, the more likely it is the carrier is going to deny the claim because, as they like to say, symptoms aren't diagnoses, Diagnoses aren't necessarily disabling. So we've got to address this in your medical records.
 
 Nancy Cavey [00:11:22]:
 And if you're treating at One of those 18 centers of excellence, they generally know how to diagnose and document the diagnosis of Ehlers Danlos. Now, one of the other issues that I see in these claims is the treatment of Ehlers Danlos syndrome. Disability carriers and plans require generally that a person get appropriate medical treatment for their condition. And what will happen in an Ehlers Danlos case is the disability carriers or plans will criticize the policyholder who hasn't gotten specialized treatment, which, of course can be difficult because it's hard to find a doctor who is proficient at diagnosis and treating EDS patients. Again, it is really crucial that whoever your physician is, that they document the basis of the diagnosis, the objective physical findings, the objective diagnostic studies, outline your course of treatment and your response to that treatment, and of course, comment on restrictions and limitations. Now, let me give you a real life example. People like Selma Blair, who is a legally blonde star, have had trouble being taken seriously. She had chronic pain and stiffness that clearly makes it hard for her to be an actress.
 
 Nancy Cavey [00:12:39]:
 And she has pointed out that a, that the treatment, it really is a team approach. Treatment. It's a team approach not only with you and your doctor, but if you're filing a disability claim, it also involves an ERISA disability attorney. In my view, it's really crucial that you are working with an experienced Ehlers Danlos attorney who understands these claims. I handle Ehlers Danlos claims not only for ERISA limited claims, but Social Security disability claims. And I will use what I do in my Social Security claim in my long term disability claim. We Social Security lawyers have developed Ehlers Danlos residual functional capacity forms which I think are a heck of a lot better than those disability carrier plans Attending Physician statement Forms. So we will use a Social Security Disability Elder Stanlow's residual functional capacity form not only in the Social Security claim, but also as an addendum to the attending physician statement form in the disability claim.
 
 Nancy Cavey [00:13:45]:
 So we're coordinating claims, we're coordinating proof, and we understand what the elements are of a diagnosis, what we expect to see in terms of symptoms, what we expect to see in treatment, in response to treatment. So we're putting together, as you should, a very linear, accurate story of the nature of your medical condition, its progression, its symptoms, and your treatment. You want to get the disability benefits you deserve regardless of where you live, regardless of the carrier. And the proof is essentially the same. So give some thought to that. Let's take a break for a moment.
 
 Speaker B [00:14:25]:
 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 that will assist you in submitting a winning disability application. This is one you don'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@disability claimsforprofessionals.com.
 
 Nancy Cavey [00:15:06]:
 Welcome back to Winning Isn't Easy. Reliance Standard wrongfully denies the claim of a nurse anesthetist with Lyme disease and breast cancer. Many disability carriers just don't understand diseases like Lyme disease. Or they may think that just because somebody has had breast cancer and has had treatment that they can return to work. And often I see claims wrongfully denied or terminated because of that thinking in quotes, if you will. So let me tell you the story about a nurse anesthetist and how her claim was denied by Reliance standards so you can have a Sense of the games the disability carriers play and the tools that they will use in their denial toolbox. A nurse anesthetist administers anesthesia during surgical procedures so that you don't feel pain. You can be administered a general, regional, or even given a sedative.
 
 Nancy Cavey [00:16:02]:
 Now, the type of the anesthesia that's given depends on the type and length of the procedure you're scheduled to undergo and your personal needs. I think we can all agree that your safety is crucial and if the nurse anesthetist is having physical problems, that your safety can be in jeopardy. Right now, diseases like Lyme disease can cause pain in the joints, muscle fatigue, fever, malaise, and even a headache. A nurse anesthetist who suffers from Lyme could easily make a mistake in administering anesthesia. Would you want them to administer anesthesia to you? Well, sometimes disability carriers don't think about those things. And let me tell you about Reliance Standards conduct in an a nurse anesthetist disability claim. Under the ERISA regulations, a disability carrier like Reliance Standard has to provide a full and fair review of a disability claim and an appeal. That means they can't cherry pick medical records to reach the desired conclusions of denying or terminating benefits.
 
 Nancy Cavey [00:17:08]:
 But of course, that's exactly what they did in the case of Jordan vs. Reliance. There are lessons to be learned in this case regardless of whether or not you have Lyme disease, because again, these are the kinds of games that carriers play with disability claims. So Jordan was a nurse anesthetist, became disabled as a result of Lyme disease that caused left sided weakness, numbness, tingling and burning from the skin, scalp to the toes. She was paid benefits from October of 2009 until May of 2015, some six years at which time her benefits were terminated. Now, in this six year period of time, the definition of disability had changed from an inability to do her own occupation to an inability to do any occupation. When her claim was denied, she filed an appeal and Reliance Standard didn't timely decide her appeal. So she filed a lawsuit.
 
 Nancy Cavey [00:18:04]:
 And then while the lawsuit was pending, Reliance denied the claim on the basis that she did not attend an IME that they had scheduled. They filed a motion to dismiss her lawsuit because her alleging that her claim was wrong and premature because she had failed to exhaust her administrative remedies because she didn't attend the IME that they had scheduled. So this case is in federal court, bounces around, and then the first go around the court says, look, Reliance, we're going to send this claim back and you can go ahead and Schedule the IME and you can issue a final decision. Of course I hate remands, but of course that's what the judge did. And of course, the alleged independent medical examination wasn't favorable. The lyre fryer IME doctor concluded that she had the functional capacity to perform any occupation within any restrictions and limitations that existed in August of 2016. Now, Reliance paid benefits through that date and then once again denied her claim on the basis that she could do any occupation. What was an interesting twist in this case is that in the course of this appeal, she began working on her master's degree, which is a two year program.
 
 Nancy Cavey [00:19:25]:
 The IME doctor, who wasn't familiar with the nature of the training program, concluded that, hey, if she can do clinical work, then she should be able to work full time. The IME doctor made unfounded assumptions about the nature of her classes, the clinical work, what was required in evaluating patients, and that was the basis of their opinion that she could go back to work. And of course, Reliance hung their hat on that unfavorable ime. So Jordan appealed a second time and she said, look, the IME doctor has made assumptions about this nursing education. That's not correct. She provided a personal statement that outlined the fact that it took four years to obtain the degree, which was a two year degree. She completed the program with accommodation, including a reduction of the hours that she was required to perform the clinical work. She even delayed her licensing exam, which she obtained a year after her graduation.
 
 Nancy Cavey [00:20:23]:
 Now, in the meantime, despite all of this, she was diagnosed with breast cancer and underwent treatment. She returned to work as a nurse practitioner in September of 2017. So you got the basic facts here. Reliance Standard had her medical records reviewed by a physician that we all know in the ERISA world who is very, very, very, very, very, very skeptical of Lyme disease. They had another peer review doctor who only addressed her breast cancer diagnosis. So guess what? They did. Each peer review provider made certain assumptions about her training, assumptions about significance of surveillance, showing her holding a leash for her dog and bending over to pet her dog. Neither of these liar for hire doctors reviewed her treating physicians reports disagreeing with their conclusions.
 
 Nancy Cavey [00:21:12]:
 And what was interesting is that the peer review reports clearly indicated that each doctor only reviewed her past medical records and did not consider her treating physicians responses or any information she supplied about her training programs. This failure would be the key to the court's ultimate decision to reverse this termination. Now, the federal court upheld the denial, and ultimately the case ends up in the sixth Circuit, who reverses. So this case has been to federal court twice and then up to the 6th Circuit. The 6th Circuit comes to the rescue and they say that Reliance Standards conclusory findings are not supported by credible medical evidence and that they acted arbitrarily and capriciously. The court took a fine tooth comb to the 11 page denial letter that recited in length all the prior medical records they reviewed. But this denial letter didn't address the treating physician's opinion, disagreeing with the peer review report, selectively considered her medical records. We call that cherry picking and did not address that.
 
 Nancy Cavey [00:22:23]:
 The surveillance that they were relying on in denying the claim was taken in 2015 when they were paying benefits. Ultimately, the court says, look, this denial letter does not pass the smell test. It doesn't adequately explain the reasoning and the inappropriate cherry picking of the medical records. The court said, look, this denial is riddled with errors and the very kind of mistakes that could kill a patient. We don't want to have to go to federal court twice and to your circuit court to get a favorable decision. So you can see that it really is crucial that you be represented by an ERISA disability attorney in the appeals process. And one who doesn't give up the documentation that was submitted should have given Reliance Standard pause to look at this and do their job. But they didn't do their job and that made it, and I'm going to put this in quotes, easier ultimately to convince the 6th Circuit that they hadn't done their job correctly.
 
 Nancy Cavey [00:23:31]:
 Winning in front of conservative judges can be really tough. And that's why proof, in my view, is really important. You need to understand the nature of the disease, the objective evidence of the disease Establishing why a person can't do their own occupation if they're attending schooling Explaining the nature of the schooling Explaining the length of time, the accommodations Explaining any attempt to return to work Providing functional capacity evaluations as appropriate Providing vocational opinions Laying the foundation for challenging a wrongful denial or termination of benefits I hope you've enjoyed this week's episode of Winning Isn't Easy. If you've enjoyed this episode, please like it, leave a review and share it with your family or friends. Subscribe please to this podcast. You'll know every time a new episode comes out. Got it. I hope you have enjoyed this week's episode and will tune in to next week's episode of Winning Isn't Easy.
 
 Nancy Cavey [00:24:34]:
 Thanks.