Home Insurance Law Consumer with Debilitating Knee Harm Awarded $247K Settlement for Wrongfully Denied Lengthy-Time period Incapacity Advantages

Consumer with Debilitating Knee Harm Awarded $247K Settlement for Wrongfully Denied Lengthy-Time period Incapacity Advantages

Consumer with Debilitating Knee Harm Awarded $247K Settlement for Wrongfully Denied Lengthy-Time period Incapacity Advantages


When a shopper with severe knee surgical procedure issues was denied a long-term incapacity declare from one of many nation’s largest insurance coverage firms, Michael Horrow and the staff at Donahue & Horrow LLP have been in a position to safe a really favorable settlement to assist the shopper give attention to his restoration. 

In December 2017, after a lifetime of onerous work, our then 58-year-old shopper was pressured to cease working after his third knee surgical procedure, on account of issues from a revision of a previous left complete knee alternative.  Whereas our shopper had been in a position to return to work after his prior surgical procedures, he by no means totally recovered from his third knee surgical procedure.  He turned to his long-term incapacity service and filed a declare for incapacity advantages beneath the ERISA-governed profit plan supplied by his employer.  

The insurance coverage firm agreed that our shopper was not in a position to work and initially accredited his incapacity declare.  For the following two years, our shopper constantly supplied up to date medical information to the insurance coverage firm. This included information from rotator cuff surgical procedure and plans for a fourth left knee surgical procedure that needed to be delayed as a result of COVID-19 pandemic.

After 24 months of receiving advantages,  the definition of incapacity modified, as is typical in ERISA-governed incapacity plans.  Initially, our shopper solely needed to exhibit that he was unable to work the job that he carried out on the time of his incapacity, that of a manufacturing supervisor, with the intention to qualify for advantages.  Nonetheless, after two years, our shopper was required to point out that he couldn’t “carry out the duties of any gainful occupation” with the intention to qualify for advantages.  Instantly after the change within the definition of incapacity, our shopper continued to obtain month-to-month profit checks.  Nonetheless, after three months, the insurance coverage firm arbitrarily and all of the sudden denied our shopper’s declare— as a result of an underqualified in-house nurse reviewer employed by the insurance coverage firm believed our shopper may return to work.

This led our shopper to method Donahue & Horrow LLP for assist with an attraction of the wrongful denial of his declare.  The Agency took over all communication with the insurance coverage firm and ensured that the insurer obtained all of our shopper’s up to date medical information in addition to reviews from a Practical Capability Evaluator and a Vocational Analyst additional supporting the declare.

When the insurance coverage firm refused to reverse its declare choice on attraction, Donahue & Horrow LLP filed an ERISA criticism in america District Courtroom for Central District of California’s Los Angeles courthouse.  Ultimately the events carried out a mediation, throughout which the insurance coverage firm agreed to pay our shopper a considerable settlement in change for a dismissal of the lawsuit.  With the settlement, our shopper was in a position to keep away from the uncertainties inherent in litigation and was additionally free of having to make month-to-month reviews to the insurance coverage firm concerning his medical situation.  Now, utilizing the cash from his settlement, alongside together with his month-to-month Social Safety Incapacity Insurance coverage advantages, our shopper is ready to spend his time specializing in his restoration and spending time together with his household, reasonably than combating with the insurance coverage firm.

In the event you imagine your incapacity insurance coverage, life insurance coverage, AD&D or long run care insurance coverage declare was improperly denied by your insurance coverage firm, name Donahue & Horrow LLP at (877) 664-5407 for a free session.



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