Pitfalls Of The Disability Application Process – Part III – The Appeal

Despite your best efforts to reach an accommodation with your employer and submit an accurately worded and detailed long term disability benefits application with plenty of supporting documentation, the insurance company denied your claim.  If you have not talked to an attorney already, you need to do so now. 

While the insurance company internal appeal process is not complicated, anything you fail to submit during the appeal process cannot be introduced later in a court challenge.  I have seen applicants who have simply written a letter as their appeal restating their belief that they are entitled to benefits.  When the appeal is denied, the opportunity to produce additional medical records and letters of support from treating physicians is lost.  An attorney can help you see what you or the insurance company may have missed and advise you of your likelihood of success. 

Employer provided disability benefits are governed by a law called the Employee Retirement Income Security Act, or ERISA for short.  The law favors the insurance companies and challenging a denial of benefits is a difficult undertaking.  To prevail, all the insurance company needs to show is that it had a “reasonable basis” for denying the claim.  Often, this standard can be met by having the applicant’s file reviewed by an “independent” physician who renders an opinion that the applicant is capable of working.  The applicant has the burden of showing the insurance company’s decision was arbitrary.  Mounting a successful challenge requires a careful legal review of the insurance company’s entire claims file and the disability policy.

You are entitled to a copy of the disability policy and your insurance company’s file regarding your claim at any time.  You must send the insurance company a written request.  If they fail to send you the documents within thirty days, the insurance company can be fined $110/day.  Every evaluation of a claims denial must begin with a request for the file. 

An applicant has 180 days after the denial to submit any additional materials for the insurance company’s consideration.  The insurance company may take up to 90 days to make a decision.

Law Offices of Scott I. Fegley, P.C.
301 Oxford Valley Rd, Suite 402 A YardleyPA19067-7710 USA 
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Pitfalls Of The Disability Application Process: Part II – After Leaving

Hopefully, you took my advice after reading Part I and tried to reach a reasonable accommodation with your employer.  For this blog, I’ll assume you made a good faith effort to find a solution that worked and either met with frustration at every step or were ignored completely.  (If you cannot work even with an accommodation, then the Americans With Disabilities Act (ADA) doesn’t help you and applying for disability benefits is your only option).

Your effort to reach a reasonable accommodation with your employer should strengthen your long term disability (LTD) application and should be noted in the application.  Although not required, it does not hurt to mention any efforts you made at reasonable accommodation in an application for either social security or long term disability benefits.  To be entitled to protection under the ADA, a disabled person must be able to work either with or without an accommodation.  Therefore, if your employer’s failure to accommodate is an issue, it is important to avoid making factual statements in disability applications that may be construed as demonstrating an inability to work at all.

Before the Supreme Court case of Cleveland v. Policy Management Systems Corp., general statements like “I cannot work any longer” or “I am completely disabled” in a disability application were used to bar a disabled person from suing a former employer for failing to accommodate him under the ADA.  Since Cleveland, generalized statements no longer preclude a disabled person from filing a lawsuit under the ADA.  However, specific statements of fact still may.   Rest assured the insurance company attorneys and the courts will scour benefits applications looking for factual statements which may contradict a disabled person’s claim that he could have continued working with a reasonable accommodation.  For example, a nurse who states in a disability application that he cannot stand for more than five minutes nor lift more than five pounds may have his ADA case dismissed because standing for long periods and lifting more than five pounds are typically essential functions of a nursing job.  Careful review of a disability application to demonstrate the steps taken to maintain employment and avoid inconsistent factual statements will not only increase the likelihood of receiving benefits, it will deny the employer’s attorney a key argument often raised to dismiss an employee’s ADA claim.

It is not only what you write, but what your doctor writes as well that should be reviewed.  Disability benefits applications generally include physicians’ certifications that must be completed by the applicant’s physician.  While “check the box” responses may not be given preclusive effect by some courts, the doctor’s specific factual statements as to what the applicant can or cannot do bind the applicant as well if submitted without any clarification or disagreement from the applicant. 

During the application process, it is important to produce all relevant medical records and have at least one physician, preferably the specialist treating the disabling condition (e.g. a rheumatologist for rheumatoid arthritis), write a letter stating specifically how the disabling condition prevents you from performing your job.  For example, the rheumatologist might write for our nurse that the arthritis prevented him from opening bottles or entering data into a computer.  This would not preclude him from later bringing an ADA claim against the employer if the employer refused his requests for voice recognition software for the computer (now readily available and affordable for most employers) or bottles that came with something other than screw-off lids for dispensing medicine.

I do not handle claims to the Social Security Administration for social security disability benefits.  Before applying for these benefits, consult an attorney who specializes in social security claims.  However, disability insurance companies will often require you to apply for social security benefits which, if granted, will reduce the amount they have to pay you.  The insurance companies may even recommend and pay for an attorney to pursue your social security benefits. 

While you may provide additional documentation to the insurance company on an internal appeal, it is much more cost effective to marshal all your evidence and provide it with your application.  Taking a little more time to properly prepare and submit the application the first time will significantly increase the chances of having your application approved, avoiding the additional time and expense of an appeal, and avoiding problems with a later claim against your employer for a failure to accommodate.

In the final blog for this series, I will discuss what to do if your disability application is denied.

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Pitfalls Of The Disability Benefits Application Process: Part I – Still Employed

I have blogged previously about the pitfalls of filling out applications for disability benefits without seeking the advice of an attorney.  Simply stating you have a disabling medical condition and providing a few records from your physician is not likely to convince an insurance company to pay you, especially if your condition is a mental illness, back injury, or some other impairment which is not obvious.  Yet, there are other pitfalls and recurring problems I have witnessed with clients that warrant a more in-depth review of the entire disability application process.

In this first blog, I’ll discuss what you need to be thinking about if you are considering applying for long term disability (LTD) or social security benefits (SSDI), but are still employed.  You may already be on some type of leave, either Family & Medical Leave or short term disability.  Too often, the employer is eager to rid itself of what it perceives as an unproductive worker and may push you towards leaving your job and applying for LTD.  They will not always tell you that it is the insurance company’s decision whether to pay benefits, and the insurance company may have a different view of whether you are ”totally disabled.”  Unfortunately, some employees resign prematurely expecting to receive disability benefits and then find themselves without any income at all.

So before you apply for disability benefits, consider whether there are any steps your employer can take to accommodate your disability and help you continue working.  These accommodations may be an adjustment of your hours, reassignment of minor tasks, providing you certain equipment (for example, a hands-free telephone headset for someone suffering from neck pain), or even a short period of additional leave after Family & Medical Leave has been exhausted.  There is no exclusive list of accommodations, so be creative and seek your doctor’s input.  However, an employer has no duty to accommodate an employee who does not ask for help even if the employer is aware of the disability.  So don’t be reluctant to ask for help!  You don’t have to use magic words or cite the Americans With Disabilities Act.  Just tell your employer “I have a disability and I need help.”  Once you ask for help, it is then the employer’s responsibility to engage in an “interactive process” with you to find an accommodation that works for both of you.  If you leave your employment without asking for help, the employer will not be at fault for not offering help and will not have to rehire you if your application for LTD benefits is denied.

As the interactive process implies, it is a two-way street.  Both parties have to look for solutions and be reasonable.  Asking a small employer to install an elevator in a two-story building so you don’t have to climb stairs may be unreasonable and a hardship for the employer, but asking to be relocated to an office on the first floor is not.  Whether a particular accommodation is reasonable will depend on the circumstances of each case and, ultimately, may be up to a jury if the parties cannot agree.  However, an employer’s refusal to engage in the interactive process at all is a clear violation of a disabled employee’s rights under the Americans With Disabilities Act.

If the employer works with you and provides a reasonable accommodation that enables you to keep working, then the goals of the Americans With Disabilities Act have been fulfilled and you won’t need to fill out any applications for disability benefits.  In my next blog, I will discuss what to do if your employer refuses your request for a reasonable accommodation and either fires you or leaves you no choice but to leave work and apply for disability benefits. 

 

 

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The Case Of The Dangerous Golden Retriever

I do not practice criminal law, but I was happy to take the case of a three-year old golden retriever I’ll call Rex who was accused of ambushing an older couple and savagely attacking their Jack Russell terrier.  I’ve mentioned in previous blogs that I am the son of veterinarians and have grown up around and worked with a variety of breeds.  I’ve also handled several civil dog bite cases for human victims.  This was the first time I had ever heard of a golden retriever attacking anything other than its supper dish. 

My client explained to me that, in a moment of haste, she apparently did not fasten the latch to the fence that enclosed the backyard where Rex and his female companion, Sophie, stayed in nice weather.  She did not know they had left the backyard until a police officer arrived at her door.  The complaining couple, neighbors who lived just down the road, were the only witnesses to the alleged attack.  In the statement I obtained from the investigating detective, the couple alleged that Sophie approached them alone from the front and they verbally shooed her away.  They claim Rex jumped them from behind knocking both of them to the ground.  He then went after the Jack Russell.  The neighbors had bruised knees and a puncture wound on the Jack Russell to corroborate their story.  After completing his investigation, the detective initially indicated he would charge my client only with failing to confine Rex to her property.  However, the neighbors wanted my client to be cited for harboring a “dangerous dog,” and so she was. 

Under Pennsylvania’s Dog Law, a dog may be judicially labeled dangerous if it severely injures another animal without provocation(defined as broken bones or an injury requiring multiple stitches), attacks a human without provocation(whether causing injury or not), or has been used in the commission of a crime.  If a dog is found to be dangerous, the consequences can be quite costly to the owner.  There is the initial fine of not less than $500.00.  More burdensome are the requirements of constructing a special enclosure for the dog on the owner’s premises with a concrete slab, chain link fencing, and a locking gate, and notification to one’s insurance company.  The cost of constructing such an enclosure and the increase in insurance premiums often lead many owners to choose euthanizing the dog instead.  Not surprisingly, my client was quite upset over the possibility of having to make a choice between thousands of extra dollars she doesn’t have to spend and Rex’ life.

Optimistically believing that no one could find a golden retriever dangerous, she represented herself and Rex in front of the local magistrate and lost.  She appealed the citation to the county Court of Common Pleas and then called me.  Rex and his companion’s inability to testify gave us a decided disadvantage.  (Dr. Doolittle was not available to serve as an expert witness).  Nevertheless, since a conviction under the Dog Law requires the same “beyond a reasonable doubt” burden of proof required in any criminal case, I was confident I could create doubt in the judge’s mind as to whether an attack actually occurred.  I believe Rex and Sophie, seeing the neighbors and their dog coming up the road, simply went to say hello.  I’d bet money the Jack Russell went after Rex or Sophie starting the fracas.  Jack Russells are an entertaining and athletic breed, but can have a serious attitude problem especially towards other dogs.  My client told me a few weeks earlier the same Jack Russell had nearly choked itself trying to get off its leash and after Rex and Sophie as they walked by their neighbors’ home.  I’d bet more money the couple fell over the fighting dogs or got tangled up in the Jack Russell’s leash.

Fortunately, I did not have to convince a judge of Rex’ innocence.  The young assistant district attorney assigned to prosecute Rex also had not encountered anything worse than wet kisses from a golden retriever and agreed to a single charge of failure to confine a dog to one’s property, a fine of $25.00, and payment of the Jack Russell’s veterinary bills, which my client offered the neighbor anyway before any charges were filed. 

Dog bite cases have serious consequences for owners and victims.  While owners must be responsible for controlling their pets, at the same time a dog should not be put in jeopardy of losing its life without proof beyond a reasonable doubt that the dog is a menace.

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Out From Behind The Desk . . . Again

I have always loved performing on stage.  I think every trial lawyer has to have some acting ability.  After all, in the courtroom the lawyer is both an actor and director, playing a role while directing witnesses and trying to persuade the jury to believe his client’s story.  A trial is simply story-telling with a purpose other than entertainment and the best story-teller wins.

My last stage role outside the courtroom was back in 1991 when I played one of the muleteers in “Man of La Mancha” at Princeton’s McCarter Theater.  After 19 years, I finally decided it was time to stop making excuses as to why I did not have the time for community theater and to audition again.  My daughter’s love of drama also motivated me and reawakened an old yearning for the spotlight.  I auditioned and will be playing the role of Marley’s ghost in the Newtown Arts Company’s musical production of “A Christmas Carol.”  The show runs from December 2nd through the 8th at the historic Newtown Theater on State Street in Newtown, PA. www.newtownartscompany.com.

Aside from the opportunity to take part in a timeless story, the role of Marley’s ghost reminds me we all have a  larger role than our individual occupations.  Business?  Would that Mankind had been my business!  Charity, mercy, benevolence and forbearance were all my business! 

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Follow-Up On Foreclosure

There was a decent article in today’s Philadelphia Inquirer entitled ”Thousands Languishing In Foreclosure Limbo Land.”  While it focused predominantly on the angst of the featured homeowners, it did echo a couple points I raised in my earlier blog and which bear repeating:

1.     Only use credit counseling agencies (like www.naca.com) which are certified by the U.S. Department of Housing and Urban Development.

2.    It is worthwhile to contest your foreclosure providing you sometimes in excess of a year in which to pursue a loan modification or transition to affordable housing.

3.    Lenders seldom pay attention to homeowners acting on their own. 

If you are falling behind with your mortgage payments, seek professional assistance from qualified counselors and attorneys right away while there are more options available to you.  “Limbo Land” is not a good place to be.

Posted in Business Law | 1 Comment

Ignoring Foreclosure Only Digs A Deeper Hole

Among the most challenging tasks I have is counseling people in danger of losing their homes.  Their stories are heartrending.  Often, by the time they come to my office, they are far along in the foreclosure process, perhaps too far for me to be able to do much for them.  Some of them have fallen victim to mortgage assistance schemes in which unscrupulous persons charge large fees to help obtain loan modifications they cannot deliver.  Today, clients came in whose home had already been sold at a sheriff’s sale.  A few months ago they paid $3,000 to a “mortgage investigation” firm who promised them that the foreclosure process would be halted while their “investigation” was ongoing.  Not true.  The foreclosure process does not stop unless the lender agrees to or unless an attorney takes legal action on behalf of the debtor.  The clients learned the hard way through a bank notice stuck to their door announcing the bank as the new owner.  After a sheriff’s sale, the likelihood of a bank undoing all the legal process it has paid for and returning ownership to the borrower at a modified interest rate is about the same as Wall Street executives giving up their bonuses.

If you are behind with your mortgage payments, please follow these suggestions:

  • ACT!  Seek professional assistance.  You are unlikely to catch up on your own and ignoring the problem will only make things worse and limit your options when you finally do seek help.

 

  • If you are not yet in foreclosure, you may take some time to interview different credit counselors and select one with a bona fide track record of helping homeowners.  Take a look at www.naca.com, the website for the Neighborhood Assistance Corporation of America.  NACA is accredited by the federal Dept. of Housing and Urban Development and they DO NOT CHARGE for their counseling services.

 

  • RUN AWAY from anyone who guarantees you they can get your lender to modify your loan.  RUN FASTER if they promise you a specific interest rate.

 

  • Read all the documents given to you by a credit or mortgage counseling agency.  Will they intervene with the lender on your behalf?  And do they have the connections to get the lender’s attention?  Or are they only promising to help you “do-it-yourself?”  Do they give you a time frame in which they will respond?  Be wary of a lack of commitment.  While they are dragging their feet, you are losing precious time.

 

  • If you are served with a complaint in foreclosure, see an attorney immediately.  At that point, credit counselors cannot take legal action for you and therefore are not as effective at slowing the foreclosure process.  Only an attorney can answer the complaint and, by doing so, gain you precious time.  An attorney is also more likely to get attention for you from the lender through the lender’s attorney. 

 

  • Be realistic.  While lenders are modifying loans at lower interest rates, lenders are unlikely to agree to a modification if your income does not support even the lower mortgage payments.  You may have to consider taking the time gained through prompt response to the foreclosure to sell your home and find more affordable housing.

 

In mortgage foreclosure, time is not on your side.  Act early, educate yourself with regard to your options and the process, and choose professionals with established credentials and a track record of helping people.

Posted in Business Law | 2 Comments

Laptop Lapse Results in Big Payday for Privacy Plaintiff

You just knew it was coming.  The Lower Merion School District approved a payment of $175,000 to the student who filed the class action against the school district over the laptop misuse and another $425,000 to his attorney. (No, solo plaintiffs attorneys seldom receive those kind of fees in civil rights cases).  And all that after paying their own attorneys in excess of $1 million. (It is much more lucrative for the big Philly firms who bill hourly at $400/hour and up.  Do you think the plaintiff and  his attorney would not have jumped at two or three hundred thousand had it been offered at the outset without all the litigation?).  Sadly, the entire fiasco could have been avoided with a clear policy and a simple consent form that even the high priced Philly lawyers should have been able to draft for about $1,000.

Consent is an absolute defense, and the only defense, to allegations of privacy violations.  If the school district had developed a consent form notifying parents of the monitoring feature embedded in the laptops and advising them the device could be activated remotely, and then required parents to sign the consent form before the student could bring one home, the laptop program would not have made a headline outside of the school district’s newsletter.  Schools routinely require consent forms before students are allowed to go on field trips.  So why wouldn’t Lower Merion think a consent form was necessary for a laptop giveaway with spyware? 

It certainly gives new meaning to the old saying that education is expensive.

Posted in Civil Rights | 1 Comment

EEOC Weighs In On Obesity A Second Time

A recent ABA Law Journal article reported that the Equal Employment Opportunity Commission has taken up the case of a New Orleans woman fired from her job with a national non-profit organization for being morbidly obese.  The EEOC asserts that the woman’s obesity did not prevent her from doing her job and that the employer’s conduct violated the Americans With Disabilities Act.  Comments following the article hotly debate whether obesity is, in fact, a disability and whether the New Orleans woman has any right to ADA protection.  However, the authors appear to be unaware that the EEOC tried to make the same argument once before and lost in EEOC v. Watkins Motor Lines, 463 F.3d 436 (6th Cir. 2006). 

 

In the Watkins case, the Sixth Circuit Court of Appeals held that obesity is not a condition protected by the ADA unless it is caused by a physiological condition.  Noting that the text of the ADA regulations defining a disability uses the word “physiological,” the court held that even morbid obesity was not a disability without a physiological cause.  Thus, obesity caused by hypothyroidism or a genetic disorder is a protected disability while obesity due merely to an overabundant appetite is not.  I did not find any other court of appeals disagreeing with the Sixth Circuit.  Thus, it is unlikely the Supreme Court will be overturning Watkins anytime soon. 

 

So what gives with the New Orleans case?  One wonders whether the woman has a physiological condition that was simply omitted from the ABA Law Journal’s reporting?  (Heaven forbid that a journalist, even for a law journal, could omit such a highly relevant fact!).  Or is the EEOC bound and determined to persuade the new justices on the Supreme Court that plain old obesity is a condition deserving of protection?

 

What do you think?  Should all obese people be entitled to the ADA’s protection whether or not their condition has an underlying physiological cause?

Posted in Employment Law | 2 Comments

All’s Fair In Love And Pretrial Discovery

Social networking sites like Facebook and MySpace have quickly become a favorite hunting ground for attorneys conducting pretrial discovery.  Whether it is a divorce attorney tracking down evidence of a spouse’s illicit affairs or a defense attorney hired by an insurance company looking into the lifestyle of a person claiming to be hindered by injuries, the photographs and other posts people leave behind when their minds are far from litigation are often a fountain of truth. 

 

In a recent New York case, Romano v. Steelcase, Inc., a judge ordered a woman injured at work to authorize Facebook and MySpace to release all of her records and posts to defense counsel (Yes, a judge can require a party to permit access rather than making the other party go to the trouble of serving a subpoena).  Apparently, there was already enough evidence in her public information to cast doubt on her claims of serious limitations.  The judge cited various Facebook and MySpace privacy policy warnings that state even private posts may become public as proof that the plaintiff did not have a reasonable expectation of privacy in what she posted online.  Moreover, in light of what the judge already viewed as facts contrary to the woman’s injury claims and sworn testimony, he was not about to allow her “to hide relevant information behind self-regulated privacy settings.” 

 

Before the advent of social networking, defense counsel were already granted wide latitude in discovery of medical records, employment records and even personal diaries, calendars and photograph albums subject always to the court’s determination of whether the sought after information was relevant to the case or was merely a “fishing expedition” or intended to embarrass and harass.  The Romano court’s decision simply applied longstanding discovery principles to a new media. 

 

Plaintiffs with legitimate injuries should not fear the expansion of discovery into their private MySpace.  Confidentiality orders can require that any information disclosed does not go beyond the litigation.  Moreover, it can sometimes be turned to a plaintiff’s advantage.  If the defense shows pictures of the injured plaintiff sipping a drink on a beach by the rolling surf, then the plaintiff can show pictures of himself surfing prior to the accident and tell the jury how he can only watch since the injury.  Having nagging back pain or other injuries does not preclude one from going on vacation nor require one, as one Pennsylvania federal judge famously noted, “to vegetate in a dark room secluded from all forms of social interaction.”

 

Of course, the plaintiff who claims to be limited to vegetating in a dark room, but who then posts a picture of herself rock climbing on a Carnival Cruise, can only fault herself for her lack of truthfulness.

Posted in Personal Injury | 2 Comments