Disability Law, Explained: Tackling Your Most Pressing Questions

Welcome to Season 5, Episode 31 of Winning Isn't Easy. In this episode, we'll dive into the complicated topic of "Disability Law, Explained: Tackling Your Most Pressing Questions."

Most people assume disability insurance and ERISA benefits will protect them when they can’t work. But the reality is often far more complicated. In this episode of Winning Isn’t Easy, we’re tackling the tough questions claimants face with insurers, employers, and the fine print buried in benefit plans. What happens if an insurance company accuses you of “coaching” your doctor? Can a separation agreement’s promise to “irrevocably release” your benefits actually stop you from making a claim? And why do insurers dismiss disabling conditions as “not severe enough” even when you can’t work? These aren’t hypotheticals, they’re real roadblocks people face every day. Disability law expert Nancy L. Cavey explains how to respond when your credibility is challenged, avoid traps in severance agreements, and push back when your medical condition is unfairly minimized. We’ll also answer listener-submitted questions, giving you practical guidance you can use right now. If you’ve worried about your rights after a claim denial, felt pressured to sign releases, or struggled to prove your condition is disabling, this episode will give you the tools - and confidence - to fight back. Winning isn’t easy, but knowing the rules puts you in control.

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

One - Can an Insurance Company Deny Your Claim by Accusing You of Coaching Your Doctor?

Two - Is a “Voluntary, Irrevocable, and Unconditional Release” of ERISA Benefits in a Separation Agreement Legally Binding?

Three - Answering Listener-Submitted Questions

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.


Listen to Our Sister Podcast:

We have a sister podcast - Winning Isn't Easy: Navigating Your Social Security Disability Claim. Give it a listen: https://wiessdpodcast.buzzsprout.com/


Resources Mentioned in This Episode:

LINK TO ROBBED OF YOUR PEACE OF MIND: https://mailchi.mp/caveylaw/ltd-robbed-of-your-piece-of-mind

LINK TO THE DISABILITY INSURANCE CLAIM SURVIVAL GUIDE FOR PROFESSIONALS: https://mailchi.mp/caveylaw/professionals-guide-to-ltd-benefits

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


Need Help Today?:

Need help with your Long-Term Disability or ERISA claim? Have questions? Please feel welcome to reach out to use for a FREE consultation. Just mention you listened to our podcast.

Review, like, and give us a thumbs up wherever you are listening to Winning Isn't Easy. We love to see your feedback about our podcast, and it helps us grow and improve.

Please remember that the content shared is for informational purposes only, and should not replace personalized legal advice or guidance from qualified professionals. 

Transcript

Nancy Cavey [00:00:00]:
 Foreign hey, I'm Nancy Cavey, National Risk and individual disability attorney. Welcome to Winning Isn't Easy. Before we get started, I have to give you a legal disclaimer. This podcast isn't legal advice. The Florida Bar association says that I have to tell you this, but now that I've said that, nothing will prevent me from giving you an easy to understand overview of the disability insurance world, the games that carriers play, and what you need to know to get the disability benefits you deserve. So off we go now. Today's episode is all about answering your toughest questions on disability insurance and ERISA benefits. We're diving deep into real world issues that people face when trying to get the coverage they paid for and the benefits of that they expect and think are going to be providing them with financial peace of mind.
 
 Nancy Cavey [00:00:57]:
 We'll discuss some of the surprising legal twists that can come up along the way. From insurance companies accusing claimants of coaching their doctors, to the fine print and separation agreements that might bar you from pursuing your benefits, to the frustrating experience of being told that your condition isn't severe enough despite you being unable to work, these are many of the questions that keep people up at night. Now, if you've ever wondered what to do when your benefits are denied, what rights you might be giving up when signing legal releases, or how to respond when your medical condition is questioned, this episode is for you. We're going to break down these questions, answer listener submitted queries, and give you practical, clear guidance on navigating these challenges. So let's jump in. I'm going to be talking about number one can an insurance company deny your claim by accusing you of coaching your doctor to say that you're disabled? 2. Is a voluntary, irrevocable and unconditional release of ERISA benefits in a separation agreement, legally binding. And then three, I'm going to answer some listener submitted questions.
 
 Nancy Cavey [00:02:00]:
 Let's take a break for a minute before we get dive into this episode.
 
 Speaker B [00:02:05]:
 Have you 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 [00:02:40]:
 Welcome back to Winning isn't Easy. Can an insurance company deny your claim by by claiming or accusing that you've been coaching your doctor to say that you're disabled? Now? Unfortunately, conspiracy theories abound even in the disability insurance world. Insurance companies and plan administrators sometimes craft elaborate theories in an attempt to deny or terminate legitimate claims. Take for example, conditions that can severely limit a person's ability to sit. So you've got a herniated disc or a failed head hip replacement or complications from an ovarian cyst. That brings us to the case of Dime vs. MetLife, which is a case out of the Western District of Washington. Now, Ms.
 
 Nancy Cavey [00:03:22]:
 Dime had a long history of abdominal and pelvic issues. She underwent surgery to remove an ovarian cyst and she experienced ongoing debilitating pain. She applied through her employer sponsored plan to get her benefits and that plan was administered by MetLife. So what did MetLife do? Well, they denied her claim and one of their reasons was that they argued without proof that Ms. Dime had orchestrated or manipulated her treating physician's language to support her disability claim. In other words, they accused her of influencing her doctor behind the scenes to write specific things in her medical records. Fortunately, the court didn't buy it and it rejected this speculative attack, stating that rather than a conspiracy, it was more likely Ms. Dimes qualified treating physician had witnessed her repeatedly experiencing the same symptoms and continued to use the same language rather than reinventing the wheel.
 
 Nancy Cavey [00:04:21]:
 Sometimes the simplest and most easy and effective way to keep consistent records is to use the same terminology. The court also emphasized that the repetition of the language in medical records isn't inherently suspicious. Why? Well, the primary purpose of medical documentation, the court noted, is to promote communication and continuity among healthcare professionals, not to serve as legal evidence in a disability determination. Now that isn't to say that you shouldn't be providing a thorough history of your symptoms or that your doctor shouldn't occasionally change or vary the wording in their notes. So here's some practical tips. At each visit, you want to give your doctor a clear, detailed history of your symptoms. So if you're having trouble, for example, sitting, you want to tell the doctor that you may have tingling and numbness that impacts your ability to sit and that you can only sit for 45 minutes at a time to get up to relieve that tingling and numbness. So you're talking about your symptoms and your functionality.
 
 Nancy Cavey [00:05:22]:
 You want to explain in this example for how long you could sit at one time, what postural changes you need to make to relieve the pain and how long those changes have to be maintained. In other words, you alternate sitting and standing or you might elevate your legs. You might be in a recliner. It might be that you are shifting from side to side, wiggling around if you will, and that you're doing that. You know every 45 minutes. So you're giving the doctor an explanation of how long you can sit at one time, what you do to maintain that posture, what postural changes you have to make, and how long it takes before those changes are no longer effective in relieving your pain. Now, you also, for example, would want to note whether your sitting tolerance or need for breaks change throughout the day. So for most folks, their pain increases in the course of a day and their ability to do things declines as the day progresses.
 
 Nancy Cavey [00:06:14]:
 They may need to take more frequent breaks or even naps. Also describe whether you need things like ice or heating pad and if you do so, how, how long you do it at one time and how often you do it in the course of a day. You also want to clarify whether medication provides temporary relief or reduces symptoms. Now, you need to be careful about that because we don't want to leave them with the impression that the medication is relieving all your pain so that you're pain free or symptom free. We want to clarify the nature of the relief that you get, how long that relief may last, and of course, whether or not you have any side effects of the medication. You obviously want to be explaining how these symptoms impact your ability to perform the material and substantial duties of your own occupation or any occupation if you're at that stage. And use examples not only at work, if you're still working, but use examples of things that you might have difficulty doing in terms of your activities of daily living. Now, make sure that what you're saying is consistent in those activity of daily living forms that the carrier's having you fill out.
 
 Nancy Cavey [00:07:18]:
 And it's also consistent with what's in your medical records. And consistency and clarity can make all the difference in getting your ERISA disability benefits and staying on claim. Got it. Let's take a break. Is a voluntary, irrevocable and unconditional release of ERISA benefits in a separation agreement with legally binding. Now, those words should give you a clue, but let's talk about the case of Clyburn versus Lincoln national is a case out of New Jersey. Ms. Clyburn worked at Brother International and signed a confidential separation agreement as part of her termination.
 
 Nancy Cavey [00:08:03]:
 And guess what that release contained. She voluntarily, irrevocably and unconditionally released Brother and its agents from any at all claims, including the kitchen sink, and more importantly, including those that could be brought under the ERISA statute. Now, in exchange, Brother forgave her repayment of advance payments that they had made in conjunction with her short Term disability claim. Sounds simple enough, but after signing the agreement and having the repayment obligation forgiven, she changed her mind and she filed a claim for her short term disability benefits. And obviously, that claim was denied by Lincoln, the plan administrator. Ultimately, this case ends up in court and Lincoln moves to dismiss the lawsuit. Or alternatively says, hey, rule in our favor based on this release. Let's talk about releases.
 
 Nancy Cavey [00:08:50]:
 The court acknowledged that as a threshold matter, valid releases can bar an ERISA claim. But first, the court had to determine whether the release language was valid under the totality of the circumstances. So in making that determination, the courts are going to generally consider a number of factors. Number one, what's the clarity and specificity of the release language? Number two, what's the policyholder or plan's beneficiary education and business experience? Number three, what's the amount of time that the individual had to consider the release before being obligated to sign it? Number five, whether the individual knew or should have known their rights upon signing, whether they were encouraged to seek or actually receive the benefit of legal counsel, whether there was an opportunity to negotiate the terms of the agreement, and whether the consideration offered in exchange for the waiver exceeded what the employee was already entitled to by contract or law. So let's apply this to Ms. Clyburn's situation. The court found that Clyburn knowingly entered into the release. It asked whether the release barred her from bringing an ERISA claim against Lincoln.
 
 Nancy Cavey [00:09:56]:
 And the court said, yeah, but that wasn't the only challenge. Ms. Clyburn said, look, this release isn't part of the administrative claims file, and you can't rely on it or use it to defend the denial during litigation. Well, the court didn't buy that one and said that was a red herring, explaining that a plan administrator like Lincoln has the authority to interpret both the plan and any related agreement, including the Release. So, unfortunately, Ms. Clyburn lost her case because of the release. But here's the kicker, and where the court did give her a break. The separation agreement stated that any party breaching the agreement would be liable for attorneys fees.
 
 Nancy Cavey [00:10:33]:
 So guess what? Lincoln asked the court to award them attorneys fees, which would have left Ms. Clyburn on the hook for tens of thousands of dollars. Now, the court rejected that request, pointing out that Lincoln wasn't seeking relief for the breach of the contract, but was rather moving to dismiss the ERISA claim, something that wasn't covered by the agreement's fee provision. So here's the lessons. Listen up. Don't sign a release without understanding what you're giving up or negotiate a carve out preserving your right to pursue vested ERISA benefits like short term disability benefits, long term disability benefits, health insurance benefits, life insurance benefits, pension benefits. In this release that she signed, it gave up a claim for everything that could have included any life insurance coverage she had, any pension benefits that she had accrued through her employment with brother in addition to giving up her short and long term disability benefits. And what did she get? Forgiveness of some short term disability benefits.
 
 Nancy Cavey [00:11:30]:
 That was not a wise decision. A Ms. Clyburn's case if your employer is offering you a release to sign in exchange for termination, you should must, in my view, have it reviewed by an employment attorney and an ERISA disability attorney to protect yourself. Got it? Let's take a break.
 
 Speaker B [00:11:49]:
 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@disabilityclaimsforprofessionals.com.
 
 Nancy Cavey [00:12:38]:
 Welcome back to Winning Isn't Easy. This is one of my favorite segments of our podcast and I'm going to answer listener submitted questions. But again, you need to understand I'm not giving legal advice here. Question number one In Massachusetts, is it legal for a high school, vocational school district to offer an ERISA governed long term disability plan to its teachers? Well, let's talk about erisa. ERISA is a federal statute that will govern, among other things, long term disability plans. There are two exceptions to coverage under the ERISA statute. If you are working for a municipality or a government agency, then your benefits are not covered under erisa. Or if you're working for a church governed type employer like Catholic Charities for example.
 
 Nancy Cavey [00:13:25]:
 In those two instances ERISA doesn't apply, the law would be the applicable state law. So in answer to this question, the high school district. In other words, it might be more likely than not it's a county. So the county can offer a disability insurance plan, but it's generally going to be excluded under the ERISA statute and therefore would be governed under state law. So hopefully you understand now the difference between an ERISA governed policy or plan and a state law governed policy or plan. Got it. All right. Question 2 I've been paying into my employer short term and long term disability plan for years.
 
 Nancy Cavey [00:14:02]:
 And now I need to file a claim. I'm being told by them that my condition isn't severe enough. How can something be disabling enough to keep me out of work, but not disabling enough for benefits under my own policy? Well, that's a great question. And it goes back to the terms of the policy or the plan, because the policy or plan will define what. What disability might be. It might be an inability to do your own occupation as that occupation is performed for your employer or by the particular geographic area that you live in. Normally, it's that your occupation is performed by the employer. But again, it could be even the broader definition of how it's performed under the Dictionary of Occupational Titles.
 
 Nancy Cavey [00:14:45]:
 So we want to start with what the definition of a disability is. Secondly, we want to look to see if the policy requires you have to submit objective proof of the diagnosis and the disability. And this is where games start. Because the common reasons for claims being denied is that there isn't an objective basis of the diagnosis or there isn't any objective basis for the restrictions and limitations. So that's common, for example, in fibromyalgia cases or Covid cases. They may say, you know, okay, we agree you have long Covid or you have fibromyalgia, but we don't think it's severe enough or that it disables you as that term is defined by the policy or plan and prevents you from performing your own or any occupation. So how do you go about proving that? Case law is really clear, that you have to establish generally evidence that you have certain restrictions, limitations that may preclude you from performing the material and substantial duties of your own occupation. Now, obviously, in the case of fibromyalgia, it can be hard to provide objective evidence of the diagnosis, but the court would expect that there would be on physical exam findings the tender points, and that there would be muscle spasm and there might be fatigue.
 
 Nancy Cavey [00:15:58]:
 There's gotta be documentation from your doctor that those types of problems are related to the fibromyalgia. Better yet, functional capacity evaluations or even CPET exams can be really helpful to provide an objective basis of the ultimate restrictions and limitations. And then, of course, you need to tie it together with a vocational opinion that says, look, in view of these certain restrictions, limitations, this person could not do the occupational duties required under the terms of the policy or the plan. I always, if we get an fce, want the doctor to sign off for it, or I also ask the doctor to complete some residual functional capacity forms. Now, these forms are forms that we Social Security lawyers have developed. I also do Social Security because I use these in my ERISA cases as a supplement to the Attending Physician Statement form that the carriers request. When you look at those APS forms, you can see that they simply do not ask the right questions. So the answer to this question is let's start with a policy.
 
 Nancy Cavey [00:17:01]:
 What's the definition of disability? What objective proof requirements do you have? Are there any subjective condition limitations? 2. We want to look at your medical records. We want to make sure that you're giving a really good history of your symptoms and functionality. Number three, we want to make sure that any restrictions and limitations assigned by your physician have an objective basis to it based on physical examination, based on the results of functional capacity evaluations. And then lastly, we want to document that in the form of a residual functional capacity form or even a letter from your doctor that addresses those functional restrictions and limitations. And remember, lastly, from a vocational standpoint, we want to tie this all together to establish that the severity of your impairment or problems preclude you from doing the material and substantial duties of your own occupation, or any occupation if you're at that stage. Got it. Well, I hope that diving into these questions helps shed some light in the complexities of disability insurance world litigation and claims, and it gave you some practical tools to better navigate your own situation.
 
 Nancy Cavey [00:18:05]:
 I want you to remember that winning disability benefits isn't easy, but with the right information and support, it's possible not only to win your claim, but to stay on claim. Got it. Thanks for tuning in to this week's episode of Winning Isn't Easy. If you found this episode helpful, please take a moment to like our page, leave a review and share it with your friends and families. And of course, subscribe to this podcast. And as you know, I love those questions. At the beginning of each episode description, you'll find a link where you can send us your questions or comments and I will probably feature them in a future episode because I want this to be an exchange of information between you and myself. Got it.
 
 Nancy Cavey [00:18:45]:
 So join us next week for another insightful discussion and thanks for listening. Sam.