The Verdict is In! Anthem improperly Denied Benefits
Kevin M. Zietz and myself represented Jeffrey Kopicko on a claim for long-term disability benefits that was improperly denied by Anthem Life Insurance Company. The case involved numerous denials of his Long-Term Disability benefits under a group plan offered by his employer.
Anthem initially tried to deny benefits due to the pre-existing clause in the plan. My co-counsel and I appealed that decision, and after proving that Anthem was wrong, they reversed their decision. However, then Anthem tried to claim that Mr. Kopicko was only approved for a closed period of time. Basically, they tried to pay him only a portion of his benefits and denied the rest of his benefits claiming he did not return to work and therefore was not “actively at work” (another requirement in the plan) and denied his benefits again.
The denial of the closed period of time was done only based upon Anthem’s doctors record review and they never personally examined him. They claimed the medical evidence did not support his claim for disability by carefully selecting only the information that helped Anthem. In doing so, they didn’t even use the full information in the records when selecting their information which explained how it was not the way Anthem’s doctors made it seem.
The worst part, Anthem’s doctors claiming to acknowledge Mr. Kopicko’s diagnosis of major depressive disorder, generalized anxiety and agoraphobia, claimed there was no evidence to support those diagnosis according to the DSM 5. (A book used by psychiatrists and psychologist to diagnose mental conditions)
Anthem’s doctors failed to even recognize Mr. Kopicko’s most troubling condition of Agoraphobia. This condition causes people to hide away, isolate themselves, and make it difficult for them to get the help they need. This caused a gap in treatment which Anthem tried to use to claim he failed to return to work and therefore was not entitled to benefits. Anthem claimed that not only did Mr. Kopicko fail to return to work, but also failed to meet the requirement of being under the continuous care of a doctor.
I, along with my co-counsel, filed a lawsuit and wanted to prove to the court that Anthem’s review was improper and that the benefits were improperly denied. After reviewing the record, the court agreed.
When looking at the Judge’s ruling it is very important for two main reasons: First: When a person suffers from agoraphobia and is unable to seek the treatment they need, (for six months or longer) they should not be denied benefits for the very disabling condition preventing them from getting the help they need. The gap in treatment argument failed and the court found it was not a proper basis to deny his claim.
Secondly, the attempt to claim a lack of objective evidence (which the plan also requires) to deny disability benefits based upon psychological conditions, is improper and you must look at the entire set of facts to make a proper determination. The court noted that psychiatric conditions are not as amenable to substantiation by objective laboratory testing like physical impairments are.
This goes to show that people suffering from mental disorders can prove they are entitled to disability benefits just like anyone else.
If you need help in obtaining your disability benefits, call our office today.
See the full text of the decision here: 38 – Memorandum of Decision & Order
Todd Krauss, ESQ
