When Insurance Companies Get It Wrong (and Sometimes Lose)

Welcome to Season 6, Episode 16 of Winning Isn't Easy. In this episode, we'll dive into When Insurance Companies Get It Wrong (and Sometimes Lose).

Insurance companies often claim they’re just “following the plan” when denying disability benefits. But in many ERISA cases, the real dispute isn’t whether someone is disabled, it’s how the insurer interprets the evidence, which medical opinions it chooses to credit, and how far it will go to defend a denial once it’s made. From surveillance footage that captures only moments of activity to peer reviews that dismiss extensive medical records, disability carriers frequently rely on selective evidence and insurer-retained experts to justify cutting off benefits. In this episode, we examine three real cases where federal courts scrutinized those tactics. We explore how insurers used surveillance to terminate Long-Term Disability payments, rejected claims involving cognitive dysfunction and dysautonomia despite significant documentation, and relied on medical opinions built on assumptions that weren’t supported by the record. Along the way, we break down how ERISA’s deferential standard shapes these disputes, why courts sometimes find insurer decisions arbitrary or inconsistent, and what these rulings reveal about the strategies carriers use during claim reviews. If you’re pursuing Short- or Long-Term Disability benefits, this episode offers a closer look at how denial decisions are defended, and what can happen when a court concludes the insurer got it wrong.

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

One - How Physical Therapy Notes Prompted Surveillance and How Hartford Used Surveillance Against a Disability Policyholder Who Suffered Chronic Pain

Two - Cognitive Dysfunction, Fatigue, and Dysautonomic Symptoms as a Result of COVID Vaccination Results in Disability Benefit Litigation

Three - How Appalachian Regional Health Care Wrongfully Denied a Disability Retirement Claim and What One Federal Judge Had to Say

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 [00:00:16]:
 Insurance companies and plans often insist that they're simply following the plan or the policy when they deny disability claims. But sometimes the record will tell a very different story, one where surveillance is overstated, medical evidence is ignored, and experts hired by the insurer reach conclusions that don't even match their own findings. I'm Nancy Cavey, national risk 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 isn't legal advice. The Florida Bar association says I have to say this I and now I've said it. Nothing will ever prevent me from giving you an easy to understand overview of the disability insurance world, the games the carriers and plans play, and what you need to know to get your disability benefits.
 
 Nancy Cavey [00:01:05]:
 So off we go now. In ERISA disability cases, the fight is rarely just about whether someone is sick or injured. More often than not, it's how the evidence is interpreted, which medical opinions are given weight, how much weight they're given, how aggressively an insurer defends a denial once it's been made. And I will tell you that disability carriers and plans frequently rely on tools. I call them disability toolbox positions. In other words, they've got this toolbox and they'll pull out these defenses, and more often than not, it's just more than one. So they will rely on tools like peer reviews, independent medical examinations, or surveillance to justify their decision. And on paper, these tools are supposed to create a fair and balanced evaluation of a claim.
 
 Nancy Cavey [00:01:57]:
 But in practice, I normally find that these are used in a way that tilt the process heavily in favor of the disability carrier. The plan so in today's episode, we're going to examine three real cases where federal courts took a hard look at these tactics. And in the first story, I'm going to talk about how routine physical therapy notes triggered surveillance that an insurer later relied on to terminate long term disability benefits, even though the footage captured only seconds of activity. In the second case, I'm going to explore a claim involving cognitive dysfunction and dysautonomic symptoms following a Covid vaccination. The insurer argued that there was no objective evidence of impairment despite extensive medical documentation. And in our final case, we'll look at a disability retirement claim where the insurer's own medical examiner conditioned his opinion on treatments that the claimant hadn't received and assumed that there was pain control when in fact there was no pain control. So these cases will illustrate how disability carriers will sometimes rely on selective evidence, narrow interpretations of medical records and opinions from insurer retained experts to justify that denied claim. And it's also going to show how federal judges will analyze decisions under the ERISA's deferential standard and what can happen when a court concludes that the insurer's reasoning was arbitrary, inconsistent, or simply unsupported by the record.
 
 Nancy Cavey [00:03:29]:
 So by the end of this episode, I want you to have a clearer understanding of how these disputes unfold and why in some cases, courts step in when carriers or plans get it wrong. So let's dive in. I'm going to talk about three things. One, how physical therapy notes prompted surveillance and how Hartford used surveillance against a disabled policyholder who had chronic pain. 2 Cognitive dysfunction, fatigue and dysautonomic symptoms as a result of COVID vaccination results in significant disability benefit litigation. And number three, how Appalachian Regional Health Care wrongfully denied a disability retirement claim and what one federal judge had to say about all this before we get started, let's take a quick break.
 
 Speaker B [00:04:14]:
 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 program process. Request your free copy of the book@kvlaw.com today.
 
 Nancy Cavey [00:04:58]:
 Foreign. Welcome back to Winning Isn't Easy, How Physical Therapy notes prompted surveillance and how Hartford used that surveillance against a disabled policyholder who had chronic pain. Disability carriers and plans are not in the business of paying claims and they're certainly not interested in paying claims for the entire policy period, even if you have chronic pain. I'm going to tell you the story of Allison Butler, who was employed at Metro West Jewish Day School as the director of student support. Now, she stopped working in 2021 because of chronic body pain, including back pain and fatigue. She filed a claim for long term disability benefits and it was approved by Hartford, who administered the disability plan and paid benefits. In 2021, she was involved in an automobile accident that worsened her pain and as her pain increased, she underwent spine surgery. Unfortunately, that surgery wasn't successful and because of pain and a foot drop, she started using a cane to work.
 
 Nancy Cavey [00:06:00]:
 Now she had injections and physical therapy between April and September of 2022. That didn't help. But guess what? The physical therapist noted she had taken two international trips, cleaned out her garage, moved boxes and hadn't used the cane for extended periods of time. And I just hate reading physical therapy notes like that. So please don't spill your guts to the physical therapist because it will be reported. But in this case, she continued to get injections without significant improvement, and her doctors continued to support her inability to work. Those physical therapy notes set off Hartford's alarm bells. And In June of 2022, they assigned surveillance.
 
 Nancy Cavey [00:06:41]:
 In the first set of surveillance, she was observed driving, carrying various items, going upstairs, entering her home. In July, she was observed bending at the waist, lifting a lawn chair, and retrieving a second chair. Armed with that information, Hartford notified her that she had to prove her inability to perform her own occupation. So as part of their investigation, Hartford sent a representative to interview her. And she should have had an attorney. You should always have an attorney in this instance. But she advised that her chronic pain made it difficult to do physical motions required of her occupation, such as bending, lifting, and going up and down stairs. She advised that she use the cane.
 
 Nancy Cavey [00:07:24]:
 And while with physical therapy, she was able to reduce the use of her cane. She still used it. She could walk 15 minutes at a time, do everyday activities like grocery shopping, so long as she hung onto that cartoon. So Hartford sent their investigative report to her treating physicians who did opine she was unable to work. But in response, Hartford had her undergo a not so independent medical evaluation who opined she could work with restrictions on a full time basis, in part based on that great surveillance film. And that resulted in a termination of her benefits. Ultimately, we end up in federal court. So what did the federal judge do with a surveillance? Well, Judge Wan reviewed five surveillance videos, and he opined that Hartford had given the surveillance undue weight in making the decision to terminate benefits.
 
 Nancy Cavey [00:08:18]:
 Of the five surveillance videos, two didn't even include her in the footage. Okay, so that leaves us three. And he noted that the three remaining videos spanned two and a half minutes, of which she was depicted for at most a minute at a time. While technically true in their characterization of her actions, and for example, she was seen carrying a grocery bag, cane, and water bottle on June 17, 2022. That film showed a slow gait and an obvious struggle in her movements. So Judge Wan criticized the short length of the observation and the conclusions that were drawn and the failure to look at the totality of the surveillance. The court noted that if an administrator has placed undue emphasis and an improper weight on certain types of evidence, the resulting determination can be arbitrary and capricious. Judge Wan agreed that Hartford had placed both undue emphasis and improper weight on the surveillance.
 
 Nancy Cavey [00:09:21]:
 But unfortunately, instead of awarding benefits, he. He remanded it back to Hartford so that they could have another chance to justify its claims denial. So what are the lessons learned here? Well, Hartford is probably going to get it right this time. But the case shows how carriers will use the most inconsequential surveillance as a way to terminate benefits. They'll attempt to get treating physicians to change their opinions about a patient's inability to work based on that surveillance. And then they're going to hire a liar for hire doctor who will impart rely on any evidence, including limited surveillance, to opine that the policyholder can work. So the important lesson here, lessons are, number one, be very, very, very careful about what you're telling the physical therapist about what you're doing in your personal life. It's going to end up in your PT records and it will be used against you.
 
 Nancy Cavey [00:10:10]:
 Number two, if you're asked to give a statement, it's time to hire an attorney. Number three, if you're asked to undergo a not so independent medical evaluation, it's time to hire an attorney. These are key stages in a claim that you need protection to protect yourself not only from them, but from yourself. Got it. Let's take a break. Sam, welcome back to Winning isn't Easy. Cognitive dysfunction, fatigue and dysautonomia symptoms as a result of COVID vaccinations results in disability benefit litigation. Now, the known complications of a Covid vaccination can include chest pain, shortness of breath, fatigue, brain fog, cognitive decline and dysautonomic dysfunction.
 
 Nancy Cavey [00:11:36]:
 But I find that disability carriers and plans are quick to dismiss these complaints and symptoms as being subjective in nature or psychiatric in nature. And I'm going to give you an example of the games that disability carriers play in the case of Doe vs. Life Insurance Company of America. Lina Doe worked as a Dynamics analyst and Separation Dynamics analyst on hypersonic missile programs at Lockheed Martin. Her job obviously required exceptional cognitive skills and including simulating missile ascent and reentry, designing thermal protection strategies and developing technical solutions to complex problems, something I certainly couldn't do. She underwent two Pfizer COVID 19 vaccinations and experienced chest pain, shortness of breath, fatigue, difficulty concentrating and dysautonomic symptoms. She was covered under an ERISA plan and she filed a claim against CIGNA Lina, who was the insurer and the administrator of the plan. Of course, her LTD benefits were denied on the basis that there was a lack of clinical findings based on diagnostic testing or physical examination that documented functional impairment.
 
 Nancy Cavey [00:12:47]:
 That's what we see all the time. She appealed and guess what? Lina changed their mind. And they determined that while she had no physical impairment, she was psychiatrically impaired for four weeks. So they paid four weeks of benefits and denied her claim. I think that's disgusting, but it's another tactic that disability carriers will use. They will create problems, if you will, that don't exist. She wasn't psychiatrically impaired. Her cognitive impairment was secondary to her fatigue and her other symptoms, not because she had a type of psychiatric impairment.
 
 Nancy Cavey [00:13:22]:
 Obviously, this case ends up in federal court. The court notes that the mere existence of an impairment is insufficient to prove disability and that the claimant has the burden of proving that the impairment is disabling. And given that standard reasoned assessments of what Doe could and could not do would be given greater weight than statements of medical diagnosis. In other words, diagnosis alone isn't going to cut it. There has to be an assessment of what a person can do or not do. And while descriptions of symptomatology are helpful, ultimately it's going to be the physicians who opine about a person's physical, cognitive, or psychiatric restrictions and limitations that will ultimately make the day. The court found that while her occupation was sedentary in nature, it required a high level of cognitive functioning. And it looked at the records and it looked at letters from her medical providers documenting their observations of her complaints and lack of functionality at multiple visits.
 
 Nancy Cavey [00:14:31]:
 They looked at statements she had given about her symptoms and functionality. They looked at statements from her family together with her personnel records. And so what the court did was looking at this total situation. It wasn't just the diagnosis, it just wasn't her personal observations or statements. So the court analyzed the dysfunction caused by the COVID vaccination by asking a number of questions. Number one, is there an objective evidence to corroborate the subjective complaints? Two, can non objective evidence support a disability claim when subjective reports are credible? Three, were Doe's subjective complaints of debilitating symptoms credible? Number four, were her symptoms personally observed by her physicians? Next, were her physicians like Dr. Bruce Patterson, specialist in vaccination injuries. Was there evidence of malingering? Are the opinions of her physicians entitled to deference over that of Lina's physicians? And the judge analyzed each of these factors and ruled in Doe's favor, awarding her her own occupation benefits? Unfortunately, the claim got sent back to Lina to determine any occupation benefits.
 
 Nancy Cavey [00:15:45]:
 But. And I understand why they did that, but clearly this is a great win for Doe and her attorney. However, I like these lessons. I think this case is a very good analysis and summary, if you will, of how a court goes about answering the question of disability based on a diagnosis, disability based on symptoms, and the cooperation, if you will, of the subjective complaints based on observations not only of the treating physicians, but physicians who specialize in this particular medical condition. Great decision and again, I think a great lesson for everyone. Let's take a quick break.
 
 Speaker B [00:16:31]:
 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 SA.
 
 Nancy Cavey [00:17:35]:
 Welcome back to Winning Isn't Easy How Appalachian Regional Health Care Wrongfully Denied a Disability Retirement Claim and what One Federal Judge had to say Let me give you some background about ERISA before we dive in here. ERISA is a federal law that governs group health insurance, life insurance, disability insurance, and pensions. It's not a friendly place for people who have retirement claims based on disability or for generally disability claims. It comes into play if there's a dispute about entitlement to benefits. So let me tell you the story of Ms. Robinette, who is a longtime ward clerk for Appalachian Regional Health Care arh, and she was covered under their pension plan. That plan provided that if a plan participant was totally disabled, they would be eligible for disability retirement benefits. Now, this plan defines total disability as a physical or mental condition that prevents a member from continuing employment.
 
 Nancy Cavey [00:18:32]:
 That sounds pretty simple, doesn't it? So let's work through the facts of this case and see how it wasn't so simple. Robinette stopped working in 2023 because of chronic back pain and congenital left hip dysplasia, and she also had degenerative lumbar spine disease. She was born without a hip and she had surgery when she was 8 years old to try to build a hip. Now, her treating provider documented over the years her progressive left hip joint pain and low back pain due to a marked lower extremity deformity. It got progressively worse and in her doctor's opinion, there came a time when she couldn't work anymore. So she stopped work and she filed a claim. ARH had her claim filed, reviewed, and they acknowledged that she had a severe hip deformity and osteoarthritis and that it could be disabling. But the peer review doctor concluded she wasn't totally disabled under the terms of the plan and suggested that she could return to work with Restrictions? Are we surprised? Hopefully not.
 
 Nancy Cavey [00:19:32]:
 Her claim was denied by the plan, and thankfully she appealed. Now, as part of the appeal review, the plan review arranged for a not so independent medical examination. And guess what? They concluded she could work in a sedentary position with adequate pain control. And her claim was denied a second time. And now we're ending up in federal court in Kentucky. The federal court noted that the plan granted was called discretionary authority. To the review committee, that means they had the discretion to make the decision. But if that decision was arbitrary and capricious, the court could overturn it.
 
 Nancy Cavey [00:20:07]:
 So what did Ms. Robinette argue to the federal judge? She argued in part that the pension committee's reliance on that IME opinion was arbitrary and capricious. And. And that the medical evidence provided compelling support that she was totally disabled, as that term was defined. So what did the court do? Well, they found correctly that the internal peer reviewer and the IME doctor didn't claim the reviewer have access to the full medical records. And there were glaring inconsistencies in the doctor's opinions. The IME doctor conditioned his conclusion that she could work in a sedentary position on her having a hip replacement. Well, she wasn't going to have a hip replacement, and she hadn't had a hip replacement at the time.
 
 Nancy Cavey [00:20:51]:
 The claim was denied, and the IME doctor said, hey, if she has adequate pain management, no reason why she can't work. But the judge said, look, that's not the issue. The issue was what was her condition at the time of the claims denial. And the court said, look, this type of contact conduct is arbitrary and capricious. The IME's medical opinions contradict the IME's clinical findings. And the IME failed to reconcile the longitudinal records which were showing a progression. Didn't have full access to the record. Failed to note she had struggled with substance abuse.
 
 Nancy Cavey [00:21:27]:
 And guess what? When you use pain medication, you can become addicted or have substance abuse problems. Never addressed the plan's conclusions. Assumed that, one, she was going to have pain treatment, two, that it was successful and that she would not have problems with controlled substances. So the judge basically said, look, how can pain management be effective when the prescriptions for opiates isn't appropriate in her personal situation? He noted that she had constant pain that kept her awake at night. That wasn't considered. So the whole denial was sort of stacked on what I call speculation. It was based on, she's going to have a certain kind of treatment, she is going to have effective pain management, she's not going to have substance abuse issues. She doesn't have problems with constant pain.
 
 Nancy Cavey [00:22:25]:
 She doesn't have problems that would interfere with her ability to sleep. And the judge said, hey, we're not going to buy this. I'm not going to buy this. And found that she was disabled from continuing employment at the time her claim was denied. She was awarded her disability retirement benefits and the judge was so unhappy with them that the judge invited her attorney to file a fee petition seeking fees and costs at the expense of the plan. So again, these are just part of the Disability Carrier Plan's tools to try to deny claims and some of the ways in which a wrongful denial or termination can be attacked. Congratulations to Ms. Robinette and her attorney.
 
 Nancy Cavey [00:23:09]:
 That wraps up today's episode of Winning Isn't Easy. Thank you for tuning in. If you found this episode helpful, please take a moment to like our page, leave a review and share it with your family and friends. Join us next week for another insightful episode of Winning Isn't Easy. Thanks for listening.