Navigating ERISA Disability Claims While Incarcerated

Welcome to Season 5, Episode 40 of Winning Isn't Easy. In this episode, we'll dive into the complicated topic of "Navigating ERISA Disability Claims While Incarcerated."

Most people assume ERISA disability benefits work the way they should: if you’re disabled and can’t work, your insurer will keep paying. But incarceration complicates everything. Insurers don’t just review your diagnosis - they scrutinize your medical records, treatment history, and whether you’re meeting every requirement for ongoing proof of disability. Missed documentation can lead to suspended or terminated benefits. In this episode, we break down the realities of managing ERISA disability benefits while incarcerated - a process full of misconceptions, unique hurdles, and insurer tactics many policyholders never expect. We start with a Minnesota farm worker whose benefits were cut off in prison, then examine a wheelchair-bound policyholder whose claim was wrongfully denied by MetLife after incarceration. These cases show how insurers interpret policy language, evaluate evidence, and where claims often derail. Finally, we turn to practical strategies: how to maintain medical documentation from inside a facility, communicate with insurers, and work with attorneys to protect your benefits before, during, and after incarceration. You’ll learn that preserving ERISA disability benefits isn’t just about your condition - it’s about documentation, communication, and strategy. Let’s dive in.

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

One - Imprisoned Minnesota Farm Worker’s Symetra Benefits Terminated

Two - Wheelchair-Bound Policyholder Wrongfully Denied by MetLife

Three - Protecting Your ERISA Disability Benefits While Incarcerated

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/


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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.

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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 ERISA and individual disability attorney. Welcome to Winning Isn't Easy. Before we get started, I've got to give you a legal disclaimer. This podcast is not legal advice. The Florida Bar association says, I've got to tell you this, I've done that. But 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. So off we go.
 
 Nancy Cavey [00:00:40]:
 Understanding the rules about a risk of disability benefits can be difference between getting paid your benefits or losing your benefits. And that challenge only grows if you are incarcerated. Now, carriers aren't just going to look at your diagnosis. They're going to look at your medical records, your treatment history, your ongoing care. They're going to want to see whether your medical condition meets the policy definition of disability and whether you're complying with the requirements like submitting documentation and attending regular medical appointments. So that can be hard to do when you're in the pokey. Now, most ERISA disability claims require that ongoing proof of disability and, and insurers will often temporarily suspend or even terminate benefits if documentation is missing. And there is a trend right now among Hartford claims, for example, where Hartford is saying, look, we want you to provide us with this report that report this and that, and you've got 60 days to do it.
 
 Nancy Cavey [00:01:36]:
 And if you're not submitting that documentation in 60 days, Hartford is denying the claim right out of the box, saying you didn't come comply with the policy terms. Now that probably will be the subject of a different podcast, but I want you to understand that meeting the production of documents and getting appropriate treatment is really crucial to getting your benefits and staying on claim. But being behind bars can add a unique layer of complexity. You may not be able to attend appointments, see your doctors, or even submit records in the usual way. And that's why today's episode is about navigating disability claims process while you're incarcerated. And I'm going to break it down into three parts. First, I'm going to look at a case involving a Minnesota farm worker whose benefits were terminated while he was in prison. Next, we're going to examine the case of a wheelchair bound policyholder who benefits were denied by MetLife after they were incarcerated.
 
 Nancy Cavey [00:02:34]:
 And then I'm going to discuss the practical strategies for protecting your benefits if you're incarcerated, from documenting your medical care to working with your insurer and attorneys. So by the end of this episode, I want you to understand that maintaining your benefits isn't just about your medical condition. It's about documentation, communication and strategy. So let's dive in. I'm going to talk about, number one, that imprisoned Minnesota farm worker whose Symmetra benefits were terminated. Number two, I'm going to talk about the wheelchair bound policyholder whose benefits were wrongly denied by MetLife. And. And three, we're gonna talk about strategy protecting your benefits while you're incarcerated.
 
 Nancy Cavey [00:03:12]:
 Before we get started, let's take a quick break.
 
 Speaker B [00:03:15]:
 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 youf 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 to today.
 
 Nancy Cavey [00:03:50]:
 Welcome back to Winning Isn't Easy. Imprisoned Minnesota Farm WORKERS Symmetra BENEFITS Terminated. Now, under ERISA disability policies or plans, you have the burden to prove each month that you're entitled to your benefits. And by providing medical evidence demonstrating that you meet the policy's definition of disability and the failure to do so can result in the denial or termination of benefits. So let me give you an example. Let's say your policy defines disability as the inability to perform the material and substantial duties of your regular occupation. And you have to prove, based on that definition, your inability to perform that occupation. So how does that go if, if you're incarcerated? So let me tell you the story about Mr.
 
 Nancy Cavey [00:04:31]:
 Bray, who had a policy that was administered by Symmetra Life Insurance Company. Now, Bray worked as a box stacker on a Minnesota farm, lifting loads of up to 75 pounds over his head and below his waist. On May 2, 2016, he suffered an on the job injury to his left shoulder, requiring three surgeries. Despite the surgeries, he had progressive problems and complications that developed in his other shoulder and in his cervical spine. He applied for his long term disability benefits through his employer Symmetra administered plan. And the plan said, look, we're going to define disability as for the first 60 months, the first five years, a sickness or injury that prevents the claimant from performing the material and substantial duties of his regular occupation. And after five years, the definition is going to shift from an inability to perform any gainful occupation. So Bray received benefits for over four years until benefits were terminated on July 16, 2022.
 
 Nancy Cavey [00:05:29]:
 Keep that date in mind here. Bray was incarcerated from early May of 2021 until early March of 2023. And you can imagine that it was hard to get medical treatment. But he also couldn't really provide updated medical documentation or proof of the ongoing care. Prison records are not the best. But after his release, he filed an appeal. And Symmetra hired two medical reviewers who concluded that those medical records, those prison medical records, didn't support restrictions from preventing him to perform any gainful occupation. So the plan administrator found that he didn't meet the policy's definition of disability and terminated his benefits.
 
 Nancy Cavey [00:06:08]:
 This case ends up in federal court. The federal court noted that there was not a lot of evidence regarding his care when he was incarcerated. And under the plan, he was required to remain under the regular care of a doctor and provide proof. Symmetra had made multiple requests for the documentation. And because he didn't respond, because he wasn't getting his mail, his benefits were initially suspended and later terminated. So during the appeal, Ray submitted 15 pages of prison medical records showing the treatment he had received. He reported his shoulder condition, but those records didn't show shoulder specific care. Of course, the question was whether even shoulder related care was appropriate or available.
 
 Nancy Cavey [00:06:44]:
 But the records certainly didn't show address the question of whether he declined any treatment. So the judge said, look, without more substantial documentation, it's going to be unreasonable to penalize him for the absence of specific treatment during incarceration. The court recognized that Symmetra had previously determined he was disabled and had paid benefits for the three years before his incarceration. And the court concluded that a pre existing factual disability could continue to justify benefits even when the legal or procedural requirements, such as providing records that could not be met because of incarceration. That's not always going to be the case, I assure you, even if you're not in jail. So the judge awarded benefits for the remainder of the own occupation, period. A good result, but one I think that is potentially case specific. Got it.
 
 Nancy Cavey [00:07:33]:
 Let's take a break. Welcome back to Winning Isn't Easy. Wheelchair bound policyholder wrongfully denied benefits by MetLife. Remember, the disability insurance companies and carriers are going to face scrutiny when their assessments clash with the realities of an insured's medical condition. And I think this is an extreme example, but one that's educational. I'm going to tell you about Rick Lelande who was injured in a hit and run accident and he couldn't work as a manager in a sterile processing department. He was at Providence Health and Services. He had spinal surgery, he had chronic pain, he had mobility deficits and he had to use a walker and a wheelchair.
 
 Nancy Cavey [00:08:23]:
 MetLife initially approved his disability claim under the Providence Group policy. But In April of 2019, MetLife learned that he had been arrested, charged and convicted of attempted murder. Prison medical records documented ongoing treatment for his pain and mobility issues. But MetLife's doctors look at the records and said no functional limitations from a physical or psychological perspective, even though of course he was still wheelchair brown. And that led to a termination of his benefits. And Lalande appealed after his release. Now, ultimately this case went to court and fortunately there was the de novo standard of review, which is important because that allows the judge to substitute their own judgment for that of met lice. So what did the court do? Well, they said, look, the preponderance of the evidence showed that his symptoms documented functional limitations consistent with the policy's definition of disability.
 
 Nancy Cavey [00:09:14]:
 And they looked, of course, at the prison medical records. The court emphasized that they were impressed by his long treatment history, his continued use of mobility aids and the treating physician's opinion. It actually gave greater weight to the treating providers who had direct knowledge of his condition over their liar for hire peer review doctors. The Judge really criticized MetLife for selectively cherry picking the medical records to fit their narrow framework to justify that claim determination. I will tell you that this case demonstrates that insurers cannot disregard treating physicians opinions even when the insured is incarcerated. In reality, I think what made the difference in this case was that the gentleman had had spinal surgery, had chronic pain, had to use a walker and was wheelchair bound before he went into prison. Does anybody think anything is going to change that there's a miraculous cure? Certainly not. Certainly not with prison care.
 
 Nancy Cavey [00:10:10]:
 And so I think it was the severity and nature of his physical functional restrictions and limitations that really impressed the court and made them say, look, this was a bogus denial. You're looking for a reason to deny and terminate benefits. And you hung your hat on that when you in fact had paid benefits prior to his incarceration. And what had changed? Well, nothing had changed. So I think that was a great result. But you can't be assured that that's going to be the result every time. Got it. Let's take a break.
 
 Speaker B [00:10:42]:
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 Nancy Cavey [00:11:28]:
 Foreign welcome back to Winning Isn't Easy. Let's talk about protecting your ERISA disability benefits while you're incarcerated. Now, being incarcerated doesn't automatically terminate your benefits, but it introduces really significant complications. So what do you need to understand to protect your benefits? Number one, you need to understand your burden of proof. You are generally required under the terms of the disability policy to get appropriate medical treatment based on the nature of your medical condition and to provide ongoing documentation to confirm your disability. We have to go back to the policy. We're looking for those two terms, but we also want to understand how the policy or plan defines the definition of disability. Is it the inability to do your regular occupation? Is it your inability to do any occupation? And of course, we need to understand what that definition is and the nature of the proof that we need to submit.
 
 Nancy Cavey [00:12:26]:
 Number two, we've got to document all of the medical care then. I think that's important before incarceration, during incarceration, and after incarceration while you're incarcerated, I will tell you that medical treatment is going to be limited, but you should be keeping a record of your interactions with the prison medical staff, including your medication logs, whether you got any physical therapy, the nature of the treatment that you got, whether you were injured or assaulted, if you will, while you're in prison. Now, if you've had prior care outside prison, obviously you want to maintain copies of that because courts are going to look at the medical records before you were incarcerated, the medical records while you were incarcerated, and then, of course, after you are released, the nature of the medical care that you have gotten. And so courts are going to often look at the totality of the treatment history rather than the isolated period. Number three, you have to communicate with your insurer. That is going to be can be difficult. And I'm going to explain in a story what we did about not necessarily communicating while my client was in jail, but generally they're going to find out that you are incarcerated. And I prefer, if possible, to actually get, prior to the incarceration, updated medical records and evaluations.
 
 Nancy Cavey [00:13:49]:
 Normally, carriers want to see documentation generally at least once a year. So we can at least buy ourselves a year, if you will. But ultimately you're going to have to provide them with medical updates. And generally that can be difficult if you are getting treatment from prison doctors, because they're not going to let you go out and get your own evaluation or see your own doctor. So you can maintain your insurance coverage. But depending on the nature of your medical Condition, you might ask for a temporary suspension of the request for documentation. So, for example, in a case where the person is getting treatment, undergone surgery, and is a bit, you know, quiescent, if you will, in the treatment because there's no improvement expected, you, you might want to say to the carrier, I've been submitting my attending physician statement forms. Here's a current exam.
 
 Nancy Cavey [00:14:41]:
 Can we extend the period of time in which for me to submit the medical documentation to a year? But you want to play that one depending on the nature of your disability, the nature of the carrier. Again, before you are incarcerated, then after you are released, you want to make sure you are seeing treating physicians and specialists, because I will tell you that of course, will generally give greater weight in these types of cases to a physician's opinion who has seen you before incarceration and after incarceration. So you want to try to maintain contact with your outside physicians or specialists and potentially have a video or zoom, if you will. Evaluation, of course, subject to the agreement and approval and permission of the particular facility, correctional facility that you're in. You also might want to be sending notes to your doctor about the ongoing problems that you have. So let's say you have migraines. You might want to continue to keep a migraine diary and send that to the doctor. Now, once you're released from the prison, you want to timely file an appeal if your benefits are terminated.
 
 Nancy Cavey [00:15:49]:
 And that should include all the applicable prison medical records, documentation of your pre incarceration medical treatment, any logs or records that you kept about the nature of your symptoms while you're in prison. And I encourage that. And then of course, documentation of your post incarceration medical treatment, preferably from the physicians who treated you originally. And again, you've got to understand these policy specific provisions because some plans will explicitly allow for a temporary suspension of benefits if you can't provide the required documentation for reasons beyond your control like incarceration. So you've got to really familiarize yourself with policy language and especially the clauses relating to ongoing proof of disability, medical examinations and benefit suspension. Let's also talk about functional limitations versus legal requirements. Courts will often distinguish between factual disability and procedural requirements. So being unable to attend regular appointments or submit records doesn't necessarily eliminate a factual disability.
 
 Nancy Cavey [00:16:49]:
 And, and I spoke about that in an earlier episode in this particular podcast, the judges may consider pre incarceration disability and prior treatment history, available records during the incarceration, and then again the post discharge medical records. And I will tell you that legal assistance is really critical in these cases, the ERISA disability law is complex and cases often involving incarceration will hinge on nuanced interpretations of policy definitions and evidence requirements and the interpretation or interaction between factual and procedural disability. So if we've got to file an appeal, we want to make sure that there's robust medical documentation that is going to explain both factually, medically and legally the nature of your disability and the fact that it shouldn't be negated by temporary inability to provide documentation. It's really crucial that, again, consistent with the terms of the policy of the plan, that that you are maintaining continuity in terms of the medical treatment. I've seen courts award back benefits for periods of wrongful termination, even when the person is in prison, but then deny the post discharge release period because the person didn't get medical treatment. So let me tell you the story of a pilot that I represented. Unfortunately, he was driving while intoxicated, resulting in the deaths of several individual. Obviously he lost his pilot's license, but he had a disability policy and he knew he was going to be incarcerated.
 
 Nancy Cavey [00:18:23]:
 So what we did in this case was to have him examined by his treating physician for his medical condition just prior to incarceration. Number two, we continued to submit documentation of his medical treatment that he received in prison, and we had gotten them to agree to an extension of that particular time in which to submit his medical documentation based on the nature of his condition. But we also had him keep logs and records of the prescriptions that he was getting, the treatment he was getting, his response to the treatment, and his ongoing symptomatology. Upon his discharge, we submitted all that information and his benefits were paid. So it was meticulous planning, strategy, record keeping, proactive communication, comprehensive documentation from his treating physician, and our guidance that helped preserve his rights and maximize the likelihood of his continuing benefits, which in fact, continued. So thank you today for tuning in to this episode of Winning Isn't Easy. If you found the episode helpful, take a moment to like our page, leave a review, share it with your family and friends, and subscribe to this podcast so you get notification when the next episode drops. Please join us next week for another insightful discussion of Winning Isn't Easy.
 
 Nancy Cavey [00:19:44]:
 Thanks for listening.