How Claimants Accidentally Destroy Their Own Disability Cases

Welcome to Season 6, Episode 18 of Winning Isn't Easy. In this episode, we'll dive into How Claimants Accidentally Destroy Their Own Disability Cases.

Sometimes the biggest threat to an ERISA disability claim isn’t the insurance company - it’s the claimant. Missed treatment, inconsistent statements about daily activities, poor documentation, or even filing a lawsuit incorrectly can destroy an otherwise valid case. In this episode, we examine three real disability claims that unraveled because critical rules weren’t followed. We explore how gaps in medical care can violate a policy’s “regular care” requirement, how everyday activities like travel or golf can be used to undermine allegations of disabling pain, and how procedural mistakes in federal court can lead to dismissal before a case is ever heard. These cases show how insurers scrutinize not only medical conditions, but also credibility, consistency, and compliance with policy requirements. We also discuss why tactics such as careful documentation, ongoing treatment, and experienced legal guidance are often essential to protecting disability benefits under ERISA.

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

One - Why Not Getting Regular Medical Care or Following Treatment Recommendations Can Doom Your Disability Insurance Claim

Two - Golfing Dooms Chronic Low Back ERISA Disability Claim

Three - Abraham Lincoln Got It Right! Why Representing Yourself in an Insurance Disability Matter Is Never the Right Move

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. Sometimes the biggest threat to a disability claim isn't the insurance company, it's the claimant themselves. Small missteps, gaps in treatment, careless statement about daily activities, or even filing your own appeal the wrong way can completely derail an otherwise legitimate claim. 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 I have to tell you this, and 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 or plans play as, and what you need to know to get the disability benefits you deserve.
 
 Nancy Cavey [00:00:58]:
 So off we go now. In ERISA disability cases, the outcome often turns not just on the severity of someone's medical condition, but on how the claim is documented, presented, appealed and litigated. Disability insurance policies contain strict requirements things like remaining under the regular care of a physician, following treatment recommendations and accurately describing symptoms, and carefully documenting limitations. When those requirements aren't met, insurance companies or disability plans seize the opportunity to deny or terminate benefits. So in today's episode, I'm going to examine three real cases where claimants sometimes unintentionally undermine their own disability claims. In the first case, I'm going to talk about how a nine month gap in medical treatment allowed a disability insurance company to deny benefits based on the policy's regular care requirement. In the second story, I'm going to explore how a claimant's own reports of activities like travel and playing golf contradicted his allegations of disabling back pain and ultimately convinced a federal judge to uphold the termination of his benefits. And in our last case, I'm going to look at what happens when a claimant tries to represent themselves in federal court and and ends up suing the wrong party and it wasn't a party a mistake that resulted in her case being dismissed with prejudice.
 
 Nancy Cavey [00:02:24]:
 Now, today, these cases will illustrate how easily a disability claim can be derailed. Not necessarily because the claimant isn't sick, injured or disabled, but because critical rules or procedures weren't followed and sometimes even damaging evidence finds its way into the record. These cases also highlight the importance of careful documentation, consistent medical treatment, and experienced legal guidance when navigating the complex world of ERISA disability claims. So my goal for you by the end of this episode is that you have a clear understanding of what the common mistakes are that can destroy a disability case and how they can be avoided. So let's dive in. I'm going to talk about Number one why not getting regular medical care following treatment recommendations can can doom your disability claim. 2. Golfing kills the chronic low back ERISA disability claim.
 
 Nancy Cavey [00:03:21]:
 It wasn't a master's win in this case. Number three, Abraham Lincoln got it right why Representing yourself in an Insurance Disability Matter Is Never the Right Move before we get started, let's take a quick break.
 
 Speaker B [00:03:36]:
 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 [00:04:00]:
 Welcome back to Winning Isn't Easy. Why not getting regular medical care or following treatment recommendations can doom your disability insurance claim. Most, if not all disability insurance policies or plans require that the policyholder or the plan beneficiary be under the regular care of a physician and follow treatment recommendations. Now each plan or policy can have a different definition of the term regular care and that can make or break your case. You need to get out your disability policy or plan and read it cover to cover. But particularly pay attention to definitions like regular care and a disability carrier plan can deny your claim on the basis that you didn't meet those policy requirements. And they don't even get to the issue of whether in fact you are disabled. They'll just simply say you violated that particular policy or plan provision.
 
 Nancy Cavey [00:04:51]:
 And this is one of the disability carrier plans favorite defenses. It's an absolute bar to getting disability benefits. So let me give you an example in the case of Jones v. Unumlife. This is a case where Jones began working for Whole Foods in 2018 as a team receiver and he participated in Whole Foods employee disability benefit plan which was insured by unum. And in 2022 he stopped working because of back pain. He was approved for his short term disability benefits. Then he was paid a few weeks of long term disability benefits before Unum denied his claim.
 
 Nancy Cavey [00:05:29]:
 Now, the denial letters never raised the issue of whether Jones had been under the regular care of a physician and the fact that he had absolutely no medical treatment for nine months. But guess what? When Jones filed a lawsuit, Unum raised this defense. Jones argued that Unum violated ERISA's law and regulations by failing to raise this regular care issue in its decision letters. Unfortunately, the court disagreed and found that the failure to raise this defense didn't prevent the court from considering the whether he met the regular care requirements for being disabled. Now, I disagree with the court's ruling on that particular issue. I think that was a clear violation of ERISA regulations, but I wasn't the judge in this case. Jones argued that the lack of medical care and failure to follow the treatment recommendations, including getting physical therapy and an mri, was a red herring because Unum's failure to pay his benefits prevented him from affording getting continuous medical care. The court didn't buy that argument.
 
 Nancy Cavey [00:06:27]:
 The courts concluded that Jones essentially stopped receiving treatment and didn't follow treatment recommendations, rejecting his argument that it was financial hardship that prevented him from getting the care. Now, the court also noted that other courts had addressed this very question of whether financial hardship can excuse the regular care provisions of a policy or plan. Now, even if the argument was going to be permitted, the problem here was that Jones hadn't offered any evidence to establish the financial hardship to prevent him from obtaining that care. In fact, the court noted that he was receiving, for this period of time, he was getting his health insurance benefits through his employer's group plan. And so the court said, look, you could have been getting that treatment while you still had your health insurance and you were still getting your disability benefits because it all overlapped, but you didn't get any treatment. So guess what? We don't buy the argument that you were having financial hardship. So the end result, the court agreed with Unum and held that Jones didn't prove he was under the regular care of a physician as required by the plan. So Unum won the day.
 
 Nancy Cavey [00:07:34]:
 So what are the lessons that you can learn here? Number one, disability policies and plans have regular care provisions. Number two, the failure to obtain that care and then to follow those treatment recommendations can be fatal to a claim even if the carrier doesn't raise the defense. Number three, gaps in treatment. They need to be explained in a way that makes sense. And lastly, what does your policy or plan actually require in terms of the treatment and are you compliant with that treatment? That, of course, is really important because another interesting provision is, and these plans is the definition of the physician to or who should be providing the care. Because some disability carriers or plans won't recognize treatment by people like acupuncturists or nutritionists or alternative methods of care. So you've got to pay attention to the language in your policy or plan from the very beginning of the claim and not learn the hard way that you screwed up. Got it.
 
 Nancy Cavey [00:08:38]:
 Let's take a break. Welcome back to Winning isn't Easy. Golfing dooms A chronic low back ERISA disability claim. Now, as we're filming this episode, we've just finished with the Masters and Rory has won his second green jacket. I'm sure that the people who are listening to this podcast aren't golfers. Like, I'm not a golfer, but they're certainly not golfing at the level of Rory did. The point here is that there's an old saying that I think is applicable here and that is everything you can say and will be used against you in the court of law. And that holds true in an ERISA disability claim.
 
 Nancy Cavey [00:09:34]:
 So I'm going to tell you the story of Michael Schmack srmak. I hope I said his name right. He was a portfolio manager at Sands Capital Management and he was a participant in their long term disability plan which was insured by United of Omaha. He had chronic low back pain and after unsuccessful treatment underwent back surgery in October of 2022. Now, United of Omaha initially approved his claim, but terminated his benefits and in June of 2024, saying, hey, you've recovered from that surgery. You need to understand that as part of any ERISA disability claim, a disability carrier plan is going to get your medical records and they're going to review those records. They're going to have your records reviewed by their internal nursing staff and they may even have your medical records reviewed either internally or by an independent physician for comments about a person's restrictions and limitations. By the way, they're also going to look at the activity of daily living forms that you have filled out on a regular basis or looking for inconsistencies.
 
 Nancy Cavey [00:10:30]:
 And by the way, they're also going to be looking at social media. They will be looking for a reason to either craft a denial or justify a denial or termination of benefits. And that's what happened in this case. So what was United of Omaha looking for in his medical records? Number one, a history of his symptoms. Number two, a history of his post operative course. Number three, post operative diagnostic studies. Number four, post op physical therapy and treatment records. Number five, post op physical exam findings.
 
 Nancy Cavey [00:11:05]:
 Number six, a history to the medical providers of his post operative physical activities and a review of the activity of daily living forms that were completed by him post operatively. So you may ask me, well, why are they looking at all this stuff? Will, they are starting to use these reviews to create, as I've said, or craft a denial or termination. One of the things, first things they're going to do is use a disability duration guideline as a baseline for determining how long you should have been disabled after undergoing different forms of treatment. Now, these disability guidelines can set the baseline for a review of the medical records and a determination as to whether a person remains disabled and as that term is defined in the policy of the plan. So once they have a basic understanding of how long you might be disabled, then the carrier plan is going to closely review the medical reports. Looking for reports of your postoperative course. Is there any reduction or improvement in your symptoms? They're also going to be looking at the postoperative diagnostic studies to see if there's any objective improvement based on these studies and then try to correlate those diagnostic studies with the post op physical exams, looking for improvement or inconsistencies between what the diagnostic studies reveal and the level of physical functioning and your complaints of pain. Well, that's not all they're going to be reviewing.
 
 Nancy Cavey [00:12:31]:
 They're going to be looking at physical therapy notes. You need to understand that physical therapy notes are a wealth of information about your own self evaluation of your symptoms and your complaints, your efforts doing physical therapy, and whether there appears to be any improvement based on the nature of the therapy, of the treatment. And you would be stunned at what information will find their way into a physical therapy note. I think of them as a gold mine for disability carriers or plants. One of the first questions the therapist is going to be asking is how are you doing? Any change, any improvement, you know, and you unfortunately start rattling off all the things that you've been doing to show that either there's been no improvement or there's been some improvement. And ultimately all the things you rattle off in that what you think is a casual conversation makes their way into your physical therapy notes. Well, what the carrier plan is going to do is compare what you're saying in these records, including your physical therapy records, to your ADL forms that you have been reporting. They're going to say, hey, is there any inconsistencies? Are there improved diagnostic studies? Are there normal physical exam findings? And they're going to do that to counter any argument that you have restrictions and limitations that would prevent you from performing your own or any occupation.
 
 Nancy Cavey [00:13:52]:
 Now, often it's your description of your physical activities that can destroy your case. So in this case, United of Omaha reviewed his medical records from his physicians that spanned many years. They looked at written statements from his physicians, they reviewed his prescriptions, and they noted that he was able to travel and engage in activities like golf. Now, it could be any activity. It could be traveling, it could be golfing, it could be tennis it could be biking, any activity. They're going to be looking at for inconsistencies between the report of your symptoms and your exam findings and say, well, if they can golf, if they can travel, if they can do this, they can do that, they ought to be able to do their own job or any other rather occupation consistent with their skill level and their restrictions and limitations. So in this particular case, the Mutual of Omaha doctors concluded that he could perform sedentary work and they had an independent neurosurgeon review the medical records who found no evidence of limitations preventing him from performing his own occupation. So you know, the result here, the claim was denied and it ends up in front of a federal judge.
 
 Nancy Cavey [00:15:05]:
 And that federal judge rejected the arguments that United of Omaha failed to employ a reasoned and principled decision making process, that the determination he could perform physical and cognitive elements were of a job or occupation were unsupported. And basically what was crucial to the judge's decision was, was evidence in the record about his ability to travel and engage in activities like golf. So the court ultimately felt that those activities contradicted and undermined his claims. And as a result, they said, you know, United of Omaha has not abused their discretion and we're going to uphold this decision. So what are the lessons learned from this case? Well, be sure to give an accurate history of your symptoms, the location, the duration, the frequency and the intensity. Give examples of how each symptoms impacts your ability to function. Be aware of the questions by the physical therapist about your activity level because everything you say will be recorded and will be used against you. Particularly if you're discussing activities like travel or playing sports.
 
 Nancy Cavey [00:16:10]:
 Be aware of how you're answering questions on the ADL forms because those forms are going to ask travel hobbies other activities that could be inconsistent with your claim, levels of pain, dysfunction and inability to do your own occupation. So honesty obviously is the key, but you need to understand that carriers or plans are going to seize on reports of post operative improvement, increased functioning and activity that is inconsistent with a claim disability as a basis for denying or terminating the claim. Now, there isn't necessarily anything wrong with travel, but let me give you an example. Let's say you're traveling by airplane from the east coast to the west coast about a five and a half hour flight and you claim that you can't sit more than 45 minutes to an hour at a time. Obviously you want to make sure that you are telling your doctor about the frequency with which you're getting up during the course of the airplane. Ride. It might be that you had assistance wheelchair assistance, getting from the terminal to the gate and from the gate back to the baggage claim area. It might be that you paid the price for traveling for a day or two and were bedridden and not able to do any kind of activities.
 
 Nancy Cavey [00:17:22]:
 So don't leave a false impression in the mind of the disability carrier or the plan about your activities. Explain what you do, the problems you had, and the price that you pay or otherwise. The price that you pay will be a termination of your benefits. Got it? Let's take a break.
 
 Speaker B [00:17:41]:
 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 2024 hours, we are giving away free copies of the Disability Insurance Claim Survival Guide for Professionals. Order yours today@disabilityclaimsforprofessionals.com.
 
 Nancy Cavey [00:18:20]:
 Welcome back to Winning Isn't Easy. Abraham Lincoln got it right why Representing yourself in an insurance disability matter is never the right move and you might be tempted to represent yourself in an ERISA disability matter in federal court. Please don't succumb to that temptation. I'm going to give you an example of why this is a bad move. This is the case of Williams v. Friendship Health and rehab center. Ms. Williams filed a lawsuit against her former employer, Friendship Health and Rehab and the Friendship Foundation.
 
 Nancy Cavey [00:18:53]:
 She claimed that benefits were due to her under her employer's long term disability plan and which was administered by MetLife. Now, MetLife denied her claim in 2024 and she filed a suit on her own. This is called being a pro se litigant. Friendship filed a motion to dismiss the claim. Why? Well, William sued the wrong entity. The judge agreed, concluding that she couldn't bring her ERISA claim against Friendship. It wasn't the proper defendant. Her claim didn't assert that Friendship managed the plan and it never named MetLife as a defendant.
 
 Nancy Cavey [00:19:27]:
 MetLife had made the decision to deny her disability coverage and as a result, Friendship wasn't the proper defendant in the ERISA lawsuit. Not only did the judge dismiss the claim, he dismissed it with prejudice, which meant she could never, ever, ever bring it again. So suing the wrong party is always fatal and in many instances can't be corrected because the period in which to amend a lawsuit has run. And there are also other reasons why you don't want to represent yourself. If you don't file an appeal, you may not have exhausted your administrative remedies. You may not be asking for the right type of relief. You might be suing in the wrong court, you may wait too long and there's a statute of limitations defense. All sorts of things can go wrong.
 
 Nancy Cavey [00:20:17]:
 And that reminds me of what Abraham Lincoln said, a person who represents themselves has a fool for a client. So please don't make the same mistake as Ms. Williams did. You should be retaining an experienced ERISA disability attorney before you stop work and file a claim. And remember, if your claim is denied, you'll only have 180 days in which to file an appeal under the ERISA statute. If you haven't hired a lawyer at that point, you darn well better. Why? Because that appeal is the trial of your case. Don't submit a letter saying you're appealing.
 
 Nancy Cavey [00:20:49]:
 That's going to be fatal to your claim, too. An experienced ERISA disability attorney will help get the claims file, review it, cover to cover, understand what medical, legal and vocational evidence needs to be developed, and write an appeal. In our law firm, our appeals are 25 to 65 pages long, and we get compliments on all the time from disability carriers or plans about how thorough our appeal letters are. An experienced ERISA disability attorney will make all the difference in helping you navigate the complex ERISA disability statute and help you get the benefits you deserve. That wraps up today's episode of Winning Isn't Easy. Thanks 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 friends and family. And we'd also love to hear from you.
 
 Nancy Cavey [00:21:37]:
 At the beginning of each episode description, you'll find a link where you can send us questions or comments, and we might even feature them in a future episode. Join us next week. Thanks for listening.