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Benefits Law Blog

Is death resulting from autoerotic asphyxiation a self-inflicted injury?

Is death resulting from autoerotic asphyxiation gone wrong an accident or is coverage under an accidental death insurance policy precluded by the policy's "self-inflicted injury" exclusion. A recent appellate court ruling overturned a lower court's determination that the language of the exclusion is ambiguous and therefore had to be resolved in favor of the insured under the doctrine of contra proferentem. In Tran v. Minnesota Life Ins. Co., 2019 WL 1894769 (7th Cir. April 29, 2019), the insurer denied benefits, claiming the insured's unintended self-strangulation was an "intentionally self-inflicted injury," an exclusion under the policy. The court of appeals, disagreeing with the lower court and with rulings from the Second and Ninth Circuits on this issue, reversed the district court's decision holding that a reasonable person would interpret [the decedent's] cause of death, autoerotic asphyxiation, to be an "intentionally self-inflicted injury."

Social media no substitute for sound medical records

When used appropriately, social media may sometimes prove to be a valuable tool to investigate personal injury and disability insurance claims. However, when an insurer improperly denies a claim for benefits based on an unjustified reliance on social media postings, the claimant may be able to turn the tables on the insurance company.

In Williamson v. Aetna Life Insurance Co., 2019 WL 1446957 (D. Nev., March 31, 2019), a federal court in Nevada took an insurance company to task for terminating a disability insurance claimant's benefits without verifying the accuracy of information contained in the plaintiff's social media postings. 

Post-Traumatic Stress Disorder and LTD Benefits

In recent years, there has been greater recognition of post-traumatic stress disorder, commonly referred to as PTSD. Many veterans returning from overseas conflicts experience PTSD, but the condition is not limited to former military. PTSD may occur following a significant injury or psychological shock and results in persistent mental or emotional distress. According to the Sidran Traumatic Stress Institute, 20 percent of Americans will cope with PTSD in their lifetime with 13 million people experiencing it at any given time.

If you have experienced a severe injury or traumatic event in your life, the effects of PTSD are very real and may affect your ability to work. Despite increased awareness of PTSD, though, disability claims resulting from that condition are often complex and difficult to prove.

Insurers send payments directly to patients depriving providers of reimbursmeent for services

A recent CNN report ("Insurer skips doctors and sends massive checks to patients, prompting million-dollar lawsuit" March 1, 2019 - https://www.cnn.com/2019/03/01/health/anthem-insurance-payments-patients-eprise/index.html) highlights a serious problem faced by medical providers such as mental health rehabilitation facilities in obtaining payment for the services they provide.  Health insurers typically allow patients to assign payment for the services they receive in order to permit providers to receive prompt direct payment for their services.  This is a unique feature of healthcare in America since this issue does not arise in countries that have single-payer healthcare since there is no need to rely on patients to pay providers for the services they receive.

Without an assignment, or in situations where insurers refuse to accept assignments, a patient who receives medical treatment submits the bill to their insurer, receives the amount payable under the terms of the coverage, and then pays the doctor or hospital directly.  The problem with that approach, and the reason why providers prefer direct payment, is to facilitate speedier payment and avoid the need for providers to pursue collection efforts against their patients. 

Post-Traumatic Stress Disorder and LTD Benefits

In recent years, there has been greater recognition of post-traumatic stress disorder, commonly referred to as PTSD. Many veterans returning from overseas conflicts experience PTSD, but the condition is not limited to former military. PTSD may occur following a significant injury or psychological shock and results in persistent mental or emotional distress. According to the Sidran Traumatic Stress Institute, 20 percent of Americans will cope with PTSD in their lifetime with 13 million people experiencing it at any given time.

If you have experienced a severe injury or traumatic event in your life, the effects of PTSD are very real and may affect your ability to work. Despite increased awareness of PTSD, though, disability claims resulting from that condition are often complex and difficult to prove.

How You Talk To Your Doctor Matters

After you experience an injury or sickness that affects your ability to work, obtaining disability benefits can be as difficult as trying to recover physically. Even if you have purchased disability insurance or have long-term disability insurance (LTD) coverage through your employer, you may not fully understand how to tap into those benefits when the time comes. What steps can you take along the way to ease this process?

As is often the case, the first steps you take are often the most important. The first visit you make will be to your doctor’s office. You trust your doctor to make the right decisions and give you the right advice about your medical condition, but how that translates from the doctor’s office to the insurance company may not always be to your benefit.

What Are Pre-Existing Conditions?

In a recent Ohio federal court ruling, Linda Hines successfully challenged Unum's invocation of its pre-existing condition exclusion when she became disabled due to anisometropia, a neurologic condition where the brain is unable to coordinate the separate images generated by each eye.   Unum maintained that the cataract surgery Hines underwent during the 3-month lookback period prior to the effective date of her coverage related to the anisometropia.  In Hines v. Unum Life Ins. Co. of Am., 2018 WL 6599404 (N.D. Ohio December 17, 2018), the court overruled Unum's determination.  

Based on the language of the policy, the court had to determine whether the treatment Hines received during the three months prior to her coverage date constituted the receipt of "medical treatment, consultation, care or services, including diagnostic measures," that caused, contributed to, or resulted in her disabling condition. The court concluded that a treatment, which triggers a later condition is not a pre-existing condition regardless of the chain of causation.

Disability Claims And Complex Regional Pain Syndrome

Complex regional pain syndrome (CRPS), formerly known as reflex sympathetic dystrophy (RSD) is a chronic pain syndrome that can occur after an injury, and its persistence is often significantly worse than the original injury. It is a difficult condition to diagnose and common for disability insurance companies to refute or deny as a compensable disability claim. The Social Security Administration, however, has published a guidance memorandum that describes the condition and offers instructive guidance to Social Security personnel, including administrative law judges, as to how disability claims involving CRPS should be assessed.

If an insurance company has denied your disability claim related to CRPS, you should not give up pursuing your claim. This disease can significantly affect your life for years to come, and you will need compensation to replace lost wages and medical bills. The insurance company should not treat your claim any differently than another claimant, and an attorney experienced in and knowledgeable about CRPS claims can assist you.

The Problem With Pain

According to the National Institutes of Health, approximately one in 10 Americans experience severe pain every day. This pain could be the result of any number of conditions. Because pain is a subjective experience, not every condition that causes pain is known -- but what is known is that pain can drastically affect your quality of life and ability to work.

Chronic pain can affect your ability to both sit for long periods of time and remain standing, interfering with your capacity to remain comfortable at home and on the job. As a result, individuals who suffer from chronic pain may need to apply for disability insurance benefits if the level of pain reaches a level of severity to precludes the continuation of work on a consistent and reliable basis.  For those who have reached that point, it is important to understand the process of applying for disability insurance and the common issues that arise in applying for these benefits.

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