It was very important that this letter covered all the aspects of my case very clearly and concisely. It had to be written ‘court ready’ as it may very well have ended up in front of a judge who would need to decide whether or not our case was clear and compelling enough to the point that one must have acted in an ‘arbitrary and capricious’ manner to deny it. In addition to laying out all the relevant facts regarding the debilitating conditions and the conditions for disability, we made very clear any misdeeds and poor case handling.
My formal appeal letter, redacted and in PDF format, can be found here.
History of Claim
We started with a history of my claim with the LTD. In my particular case it is an employer funded plan administered by a third party administrator (TPA). At one point they switched TPAs and it was the new TPA that promptly terminated my claim. We discussed the entire history through both administrators and discussed the termination letter. Throughout this discussion we pointed out several of the flaws in their reasoning, referring to later discussion of them in more detail. We then listed all the exhibits included in the appeal file.
Plan and ERISA Review
Your appeal must address the specific reasons you were given for the termination. These must be spelled out to you in the termination letter you receive. At this point in the letter we reviewed the reasons given by the LTD and then referred directly to the section of the plan document covering that issue. My attorney then presented a rather lengthy review of ERISA regulations relative to LTD claims.
Statement of Conditions and Education
After noting the diagnoses that I have and noting that they are to the extent that I am unable to work, we went on to give the LTD a thorough education on those illnesses. My primary conditions include Chronic Fatigue Syndrome, Dysautonomia, and Hypersomnia. Over six pages we educated them on these illnesses, including quotes from some of the most noted physicians and researchers as well as citing pages from the NIH, National Dysautonomia Association, etc. In the Exhibits section of the appeal we included copies of all book and website pages that we included in the appeal letter, and a few more.
Medical Treatment
We went through each medical and neuropsychological professional that examined me and quoted extensively from their reports/statements. We concluded this section by noting “It is thus abundantly clear that [CLAIMANT] is incapable of performing not only the duties of his prior managerial position with [EMPLOYER] but also the duties of a Market Research Manager, Product Development Manager, and Product Development Supervisor that [TPA] contends he is capable of performing.”
Rebut Termination Reasoning
We extensively reviewed each of the reasons the LTD gave for claiming that the ‘severity’ of my ‘alleged symptoms’ was not ‘credible’. Their rationale included that I performed some volunteer activity and one day was seen driving
We began by addressing the volunteer and surveillance activities, reiterating some of the previous education on my illnesses, and showing that it was not only not contradictory to my ‘alleged symptoms’, but actually are consistent with the known medical In addition to pointing out the flaws and misrepresentations in their analysis, we corrected their misunderstandings and educated them on the importance of some level of activity for anyone with a chronic illness and the danger of deconditioning. Citable sources included. In this section we quoted extensively from the specialists that addressed the contentions that the LTD made.
Discredit LTD’s Process
The claim file was a wealth of information on how the claim was handled internally by the LTD. The case manager was either incredibly incompetent or blinded by her bias; but most likely both. Each of her entries was evaluated and her actions over the review period were carefully analyzed. There were countless ERISA violations as well as examples of bad faith. The most flagrant cases were presented with our full and detailed objections; once again, explaining them as if to a judge.
The background of their hired gun ‘Physician Advisor’, Dr. David L. Hinkamp, was researched and we discovered that he was a generalist Occupational Medicine physician with no apparent background or publications in any of my conditions, including CFS. The research also discovered that he was on the staff of the same university with Dr. Renee Taylor, unquestionably one of the nation’s leading medical researchers in Chronic Fatigue Syndrome. The two pages in the letter addressing that are probably the most amusing reading you will find in an appeal letter. We addressed each of the deficiencies in his analytical approach to the case. Relevant case law was cited showing that his opinion simply would not stand up in court.
The ‘Job Accommodation Specialist’ work was also evaluated and found to be superficial at best. The anemic amount of information she received gave her no opportunity to see if I was capable of actually performing the positions she eventually came up with.
You really have to do your homework and find everything you can about the LTD handling of the case; this is your only chance to provide information that may eventually be in front of a judge. I have no doubt that, despite the overwhelming medical evidence in my file, part of the reason the termination was overturned was the LTD did not want this case and their handling of it to become part of the public record.
Need for Objective Medical Evidence
One of the issues in the termination was the ‘lack of objective medical evidence.’ After reminding them of the relevant court cases affirming that objective medical evidence could not be required in Chronic Fatigue Syndrome cases, we reviewed the extensive set of objective medical evidence I actually do have. We summarized all the medical experts that agreed with my disability, and the relatively irrelevant non-specialists that took the position that I was not disabled. It was quite a lopsided presentation.
Conclusion
The letter concluded with a very brief but very concise review of the most relevant issues and reminded them of their responsibilities under ERISA.