Consumer with Debilitating Knee Damage Awarded $247K Settlement

When a consumer with critical knee surgical procedure problems 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 capable of safe a really favorable settlement to assist the consumer concentrate on his restoration. 

In December 2017, after a lifetime of laborious work, our then 58-year-old consumer was compelled to cease working after his third knee surgical procedure, because of problems from a revision of a previous left whole knee alternative.  Whereas our consumer had been capable of 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 below the ERISA-governed profit plan supplied by his employer.  

The insurance coverage firm agreed that our consumer was not capable of work and initially accredited his incapacity declare.  For the following two years, our consumer repeatedly 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 because of the COVID-19 pandemic.

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

This led our consumer 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 consumer’s up to date medical information in addition to experiences from a Useful Capability Evaluator and a Vocational Analyst additional supporting the declare.

When the insurance coverage firm refused to reverse its declare determination on attraction, Donahue & Horrow LLP filed an ERISA grievance in the USA District Court docket 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 consumer a considerable settlement in trade for a dismissal of the lawsuit.  With the settlement, our consumer was capable of keep away from the uncertainties inherent in litigation and was additionally free of having to make month-to-month experiences 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 consumer is ready to spend his time specializing in his restoration and spending time together with his household, moderately than preventing with the insurance coverage firm.

When you consider 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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