Disability Insurance
In modern times, most people need an attorney to assist them with their disability claims. Whether you have a private disability insurance policy that you purchased on your own or an employer-provided group insurance policy, you need an expert who has studied the inner-workings of powerful disability insurance companies and who has time and time again beat them at their own game.
Vast Experience in the Disability Insurance Arena
Own Occupation Disability Insurance
Common Tactics
Residual v. Total Disability
Proof of Loss
Insurer's Medical Examination
Gisonni & Harms' Legal Services Offered to Clients With Private Disability Insurance
Making a Claim for Disability Benefits
Litigating Against the Company for Breach of Contract
Employer-Provided Disability Insurance
ERISA Pitfalls
Harsh Deadline for Submission of Appeals
Disadvantage in Providing Information to Support Appeal
Unfair Deference Given to Insurers/Claim Administrators By Courts
Employee Frustration
Gisonni & Harms' Legal Services Offered to Clients With Employer-Provided Disability Insurance
Making a Claim for Disability Benefits
Appealing a Denied ERISA Disability Claim
Litigating Against the Insurance Company or Plan for Return of Disability Benefits
Vast Experience in the Disability Insurance Arena
Over the course of the past 15 years, Eve-Lynn Gisonni of Gisonni & Harms, LLP has successfully gone to battle against UNUM Corp. (The Paul Revere Life Insurance Company, Provident Life & Casualty Insurance Company, First UNUM Life Insurance Company, UNUM Life Insurance Company of America), The Guardian Life Insurance Company, Berkshire Life Insurance Company of America, The Equitable Life Insurance Company, Disability Management Services, Metropolitian Life Insurance Company, Prudential Life Insurance Company and other disability insurance companies. She has personally witnessed the corporate and financial changes that these insurance companies have gone through and the deleterious impact on people insured under these policies. Several years ago, Eve-Lynn partnered with experienced litigator, Richard Harms, who previously represented insurance companies. He has brought to Gisonni & Harms an extraordinarily valuable perspective which they use to disarm insurance companies.
Eve-Lynn has flown across the country to disability companies' headquarters to take sworn testimony of insurance company employees who have denied her clients' claims. She has cross-examined doctors hired by insurance companies who have provided biased and incorrect opinions about the medical conditions her clients suffer from. She has stood in courtrooms to face jury forepersons delivering verdicts and deciding the fate of her clients and the insurance companies. Eve-Lynn has negotiated innumerable lump sum and other settlements of her clients' claims.
The firm maintains detailed and comprehensive confidential files about each insurance company, their physicians, their employees and their claim procedures to use as a foundation for the firm's cases against those insurance companies. Because of the intensity with which Eve-Lynn has handled disability claims over the years, she has become a walking encyclopedia of each company's claims and settlement philosophy. Because of her professional demeanor, she and the firm has earned the respect of the legal counsel of numerous disability companies and maintains routine direct contact with them.
Gisonni & Harms has never been afraid to challenge an existing principle of law which was not fair to their clients. They have authored an infinite number of legal briefs championing her clients' legal positions. Their efforts in these cases are routinely reported in law reporters and on-line with Lexis and Westlaw, so that other lawyers and courts may rely on these opinions and principles of law. See Gisonni & Harms News. Eve-Lynn has attended and presented lectures in the disability field. See Gisonni & Harms News. The firm subscribes to publications which keep them apprised of all developments in the disability field across the country. Their cases are routinely reported in a well-known national disability reporter.
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Eve-Lynn and Richard have never lost sight of the reason they do this - - compassion for their clients. People who suffer from a physical or emotional disability generally come to a disability attorney when they are most vulnerable. Not only do they spend their days in physical or emotional pain or distress, but with a denied claim, they now have an extra burden of dealing with an insurance company in a confusing field that does not hold the disabled person's interests as paramount.
The firm's philosophy is to view a disability claim from three perspectives. First, they step into the shoes of the client. They study their life, their symptoms and their pain so that they can effectively convey our clients' feelings to the insurance company and advocate the merits of their claim. They study the diagnoses of their medical or emotional disability and counsel with physicians and other health experts in those medical fields to better understand the symptoms of, and side effects of medication for, these conditions.
Next we step into the shoes of the insurance company and view the claim from its perspective to identify issues which could be preventing the insurance company from handling the claim in the appropriate manner.
Finally, as litigators and business people, the claim is viewed from the perspective of what makes sense financially and practically for the client. This includes the length of time our representation may take in a particular circumstance, claim or litigation strategy, and what makes sense for the client in a retention relationship. With their clients, the firm considers their goals concerning representation, the merits of their claims, and the cost of claim and litigation time. Importantly, the firm is forthright about the strength and weaknesses of our clients' claims and find that our practice of telling the client "the way it is" from the beginning of the case through the conclusion enforces the special attorney-client relationship we value. The firm is proud of its track record of continuing to maintain relationships with its clients even after the end of their case.
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Own Occupation Disability Insurance
The firm has witnessed a trend exacted by disability insurance companies in the past two decades of disavowing the promises they made to you when you purchased these policies. Years ago, your insurance agent might have told you that the reason these policies are so valuable is because if your disability prevented you from performing your occupation, then you would qualify for disability benefits - - even if you could perform some other occupation. Disability companies are refusing to honor that promise to you, as evidenced by their aggressive claim administration procedures and unbridled willingness to disbelieve everything you and your physicians say about your condition.
Disability insurance companies routinely employ claim procedures to wiggle out of the promises they made in your contract.
Pre-existing Condition Denials
All group disability policies contain a Pre-existing Condition Limitation which allows the insurance company to delay your receipt of benefits if you are disabled and suffer from a pre-existing condition. Most companies are refusing to pay any benefits if your date of disability starts within the first 12 months of your coverage. In the case Benesowitz v. MetLife, we fought this battle and won by getting the highest Court in New York State to issue a decision stating that companies cannot bar benefits for pre-existing condition claims. See Gisonni & Harms Case Stories.
Residual v. Total Disability
Many policies contain both total and residual (or partial) disability provisions. Under the residual provisions, companies can reduce your monthly benefit on income you are receiving from work in another occupation. Often, companies disregard your claim for total disability and administer your claim under the residual disability provisions to save the company money. In some cases, this sneaky technique can also limit the maximum pay out of your policy from lifetime benefits to termination of a claim at age 65.
Proof of Loss
When you purchased your policy, you might have been told that if you become disabled, all you need to do is submit a claim form and your medical records, and if your doctor agreed you could not perform your occupation because of your condition, then the company would pay your monthly benefit. Today, some disability companies refuse to accept your reports of limitations and your doctors' opinions concerning your conditions. Instead, some companies impose their claim representatives' opinions and their physician-employees or biased outside physicians' opinions about your condition. Generally, the company representatives have never even met you and their physicians operate under an allegiance with the company and are far from independant or objective.
Insurer's Medical Examination
Generally, the insurance company is not allowed to change the promises it made to you in your policy. Likewise, you are not allowed to pay smaller premiums than you originally agreed to. However, disability companies routinely ask you to do things that you never bargained for. The physical examination clause in a policy allows the company to request that you undergo a physical examination by a physician of the company's choosing, while a claim is pending. However, many companies go beyond the four corners of this clause to demand that you submit to physical or psychological testing or to a Functional Capacity Evaluation (FCE) even though those procedures are not specifically authorized in your policy. Both testing and FCEs can be physically harmful to disabled people. Next, these procedures are often unnecessary and are a claims tool to unfairly support a denial of benefits.
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Gisonni & Harms' Legal Services Offered to Clients With Private Disability Insurance
Gisonni & Harms represents people in various stages of their disability claims.
Making a Claim for Disability Benefits:
- Gisonni & Harms serves as the client's agent in communicating with the insurance company
- Gisonni & Harms assists the client in understanding claim forms and the policy language
- Gisonni & Harms counsels clients about whether they are required under their policy to give the company certain information
- Gisonni & Harms discusses with clients the state of the law as it relates to their insurance policy provisions
- Gisonni & Harms attends Insurer's Medical Examinations (IMEs) with the client
- Gisonni & Harms negotiates monetary resolutions of claims
- Gisonni & Harms serves as a liaison between clients and their medical professionals to gather medical documentation for their claims
- Gisonni & Harms ensures that the disability insurance company is forwarding the clients' benefit checks timely and in the correct amount
Overturning a Denied Claim for Disability Benefits:
- Gisonni & Harms communicates with the insurance company representatives to identify the basis for the denial or termination of benefits
- Gisonni & Harms facilitates procurement of medical and other records which assist in reversing the insurance company's decision
- Gisonni & Harms communicates with the appropriate insurance company personnel with whom the firm can effectively convey the clients' position
- With the client, the firm will assess the pros and cons of commencing a lawsuit for breach of contract
- In the appropriate cases, Gisonni & Harms discusses settlement of the disputed claim with the appropriate insurance company representative
Litigating Against the Company for Breach of Contract
- Gisonni & Harms develops a trial strategy with the client; this includes identifying the goals in the litigation, the number and types of depositons intended to take, the legal issues which could arise during the litigation, a time line of medical treatment of the client, the medical and other types of experts we will rely on, whether litigation will be in state or federal court, the time commitment required by the client, and identification of witnesses the firm will rely on to support the clients' legal position.
- Gisonni & Harms constantly revisits the strategy during the course of litigation.
- Gisonni & Harms communicates with its clients throughout the litigation to keep them apprised of the status of the case.
- Gisonni & Harms determines the appropriateness of discussing settlement of the litigation and at the appropriate stage of the litigation.
- Gisonni & Harms employs our trial strategy from inception of the case through the trial or settlement.
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Employer-Provided Disability Insurance
If you are reading this section, then you have probably been exposed to the term ERISA. It stands for the Employee Retirement Income Security Act. This is a federal statute enacted by Congress in 1974 which sets the rules about how disability companies or your employer's claim committees can treat you under your disability plan. Originally, ERISA was set up for the protection of employees who were counting on the money in self-insured pension plans to be there when they retired. Unfortunately, the law has developed over the past 30 years to give employers and insurers an unfair advantage in ERISA disability claims.
With certain exceptions, ERISA governs most employer-provided disability insurance. However, only an attorney experienced in ERISA disability claims can make that determination. Frequently, an insurance company or claim administrator operates as if ERISA applies when it does not.
ERISA Pitfalls
Harsh Deadline for Submission of Appeals
The ERISA law identifies a strict deadline for appealing the decision of the insurance company or claim administrator which refused to pay your benefits or terminated benefits you were receiving. Routinely, an employee fails to meet the deadline because of a lack of understanding about the ERISA rules or because he does not feel well enough to appeal the adverse decision within the deadline. With certain minimal exceptations, an employee's failure to appeal the deadline within the prescribed time limit will mean he has lost his opportunity to appeal and to pursue his benefits in a court of law.
Disadvantage in Providing
Information to Support Appeal
Most disabled employees, and most non-ERISA attorneys, do not understand how to effectively appeal an adverse disability determination. With certain carved out exceptions, in an ERISA litigation, most courts will not allow the employee to submit any additional evidence to support his case that was not provided to the insurance company or claim administrator during the claim and appeal process. This places an employee at a huge disadvantage.
Unfair Deference Given to Insurers
and Claim Administrators By Courts
Depending upon how your disability plan is worded, the court presiding over your ERISA disability case may be required to side with the insurance company's or claim administrator's decision on your claim. This results in an often case-ending disadvantatge to you. There are certain legal ways to get around this strict rule, and counseling with an experienced ERISA attorney is your best bet in identifying a way around the rule.
Employee Frustration
Generally, the people who work for your employer who you trust to assist you with your ERISA disability claim are inexperienced and unknowledgeable about the procedures identified in the ERISA statute. This is a recipe for conflict between you and your employer or insurance company. Regardless if your plan is administered by your employer or by an insurance company, they are still required to follow the ERISA rules.
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Gisonni & Harms' Legal Services Offered to Clients With Employer-Provided Disability Insurance
Gisonni & Harms represents people in all aspects of their ERISA disability claims.
Making a Claim for Disability Benefits:
- Gisonni & Harms serves as the client's agent in communicating with the insurance company or employer
- Gisonni & Harms assists the client in understanding deadlines, claim forms, the plan language and the ERISA rules
- Gisonni & Harms cousels clients about whether they are required under their plan to give the company certain information
- Gisonni & Harms discusses with clients the state of the law as it relates to their insurance plan and if the court will apply a deferential review favoring the insurance company or employer
- Gisonni & Harms attends Insurer's Medical Examinations (IMEs) with the client
- Gisonni & Harms negotiates monetary resolutions of claims
- Gisonni & Harms serves as a liaison between clients and their medical professionals to gather medical documentation for their claims
- Gisonni & Harms ensures that the disability insurance company or employer is forwarding the clients' benefit checks timely and in the correct amount
Appealing a Denied ERISA Disability Claim:
- Gisonni & Harms communicates with the insurance company representatives or employer to identify the basis for the denial or cessation of benefits
- Gisonni & Harms gathers medical and other documentation to effectively appeal the denial decision
- Gisonni & Harms assists the client in understanding deadlines, claim forms, the plan language and the ERISA rules
- Gisonni & Harms identifies the deadline for the appeal and ensure that the client meets his obligations within the deadline specific to his claim
- Gisonni & Harms identifies and enforce the insurance company's or employer's deadline to render a decision on the appeal
- Gisonni & Harms communicates with the appropriate insurance company personnel or employer with whom we can effectively convey the clients' position
- In appropriate cases, Gisonni & Harms discusses settlement of the disputed claim with the appropriate insurance company or employer representative
Litigating Against the Insurance Company
or Benefit Plan for Return of Disability Benefits
- Gisonni & Harms develops a strategy with the client; this includes identifying our goals in the litigation, the number and types of depositions we intend to take, the legal issues which could arise during the litigation, a time line of medical treatment of the client, the information in the client's claim the firm will rely on and the time commitment required by the client.
- Gisonni & Harms constantly revisit its strategy during the course of the litigation.
- Gisonni & Harms communicates with its clients throughout the litigation to keep them apprised of the status of the case.
- Gisonni & Harms determines the appropriateness of discussing settlement of the litigation and at the appropriate stage of the litigation.
- Gisonni & Harms employs its case strategy from inception of the case through the conclusion of the case.
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