New York State
James J. Wrynn Superintendent of Insurance 25 Beaver Street New York, N.Y. 10004
|ISSUED 12/07/2010||FOR IMMEDIATE RELEASE|
Jane Griffin, whose long-term disability benefits were cut off when an insurer refused to consider new information about her physical condition, learned that it is possible to challenge an insurance company and win.
Griffin saw her monthly disability benefits restored after she complained to the New York State Insurance Department that her insurer didn’t fully investigate her physical condition.
“They knew something was wrong, but they cut me off out of the clear blue sky,” Griffin said.
“This woman’s worsening medical condition prevented her from going back to work. Her insurer agreed to reevaluate the case only after the Insurance Department advised the insurance company that it had to take into account new information about her condition,” Insurance Superintendent James Wrynn said.
The controller and human resources director for a Schenectady County business, Griffin became seriously ill in 2008. She was hospitalized on three separate occasions before leaving her job in January 2009. She received various medical tests and underwent surgeries for a number of ailments, including a colon condition and hernia.
Unable to work because of her condition, Griffin started receiving benefits under a short-term disability policy. In mid-2009, the short-term disability coverage converted to coverage under a long-term disability policy.
In January 2010, her insurer notified her by mail that she was capable of returning to work based on some medical reports and that it was going to stop her disability benefits. The insurer also advised her that she was permitted to file an appeal with the company to contest its decision.
Griffin appealed because she was diagnosed with a spinal condition a month before the insurer’s decision to cut off her benefits. While the company was considering her appeal, she continued to receive medical treatments including pain medications, spinal injections and physical therapy. She also underwent several MRIs and other tests.
She was then notified that the insurer still wanted to cut off her benefits despite her newly diagnosed spinal condition.
The insurer was “upholding their original decision to deny further benefits claiming that as long as I was allowed to change positions for comfort that I was capable of working on a full-time basis,” she said. The insurer told her that her only recourse was to bring civil action against the insurer.
“There are only a couple lawyers willing to take a case like this and when they do, they want $3,000 to $5,000 up front. I couldn’t afford it, but ultimately I probably would have borrowed the money to do that,” she said.
Then Griffin’s husband, Ted, learned that the denial of a claim by an insurer can be contested by filing an appeal with the Insurance Department. So, she filed a complaint with the Department’s Consumer Services Bureau, telling the Department that the insurer had failed to fully investigate her condition when it denied her appeal.
The Insurance Department’s complaint examiner determined that the long-term disability policy was a fully-insured plan, issued and delivered in New York State, bringing it under the jurisdiction of New York law. The examiner insisted that the insurer needed to take into consideration the new information concerning Griffin’s spinal condition. Based on its review of those medical records, the insurer then agreed to restore her monthly benefits.
“Through your efforts and perseverance, my disability company reinstated my long-term disability claim,” Ms. Griffin told the Department after her benefits were restored. “It was a very difficult nine months for me, but you were able to allow me to get justice. I am also grateful to Sen. Roy McDonald, whose office also stepped in to see that my benefits were restored.”
Disability insurance policies provide individuals with financial support when they suffer disabling illnesses or injuries and are unable to work. Short-term policies provide benefits usually for six or nine months, depending on the policy. Long-term policies provide benefits when short-term disability expires and continue until the individual returns to work, dies, or becomes eligible for pension benefits.
Consumers should contact their insurance company, agent or broker to discuss their specific insurance questions. They should also feel free to contact the Insurance Department’s Consumer Services Bureau from 9 a.m. to 5 p.m., Monday through Friday toll-free at 800-342-3736 if they need further help. Additional information is available on the Department’s website, www.ins.state.ny.us.