A Florida federal court finds Guardian Life Insurance Company of America did not conduct a full and fair review of Mr. Hari Sami’s, a former Shipping Supervisor, claim for long-term disability (“LTD”) benefits dur to a stroke.
Background
Hari Sami worked as a Shipping Supervisor for Contec, LLC. Through his employment, Mr. Sami was covered for long-term disability benefits with Guardian Life Insurance Company of America (“Guardian”).
Mr. Sami suffered a transient ischemic attack (“TIA”) in April 2016. A transient ischemic attack (TIA), sometimes called a "mini-stroke," is a temporary blockage of blood flow to the brain that causes stroke-like symptoms such as sudden weakness, confusion, or difficulty speaking. These symptoms typically resolve within minutes to hours but depending on what part of the brain the TIA occurs; other issues can arise such as migraines or vertigo. Following the TIA, Mr. Sami began suffering from neuralgia, chronic migraines, vertigo, and visual difficulties. He was no longer able to continue working. So, he filed a claim for LTD benefits.
Guardian approved Mr. Sami long term disability claim and paid benefits for about four years before terminating Mr. Sami’s LTD benefits in July 2020. Mr. Sami appealed Guardian’s long-term disability claim denial, but Guardian dug its heels in and denied the appeal. He then pursued a lawsuit against Guardian for the denied LTD benefits.
The Court’s Review
The Florida Court ultimately found Guardian did not conduct a full and fair review of Mr. Sami’s appeal for LTD benefits.
The Case: What Happened?
Specifically, the Court held that Guardian denied Mr. Sami’s appeal but failed to comply with ERISA law requiring claimants to receive all evidence used against them before a final decision. Instead, Guardian provided Sami with critical medical reports on the same day they issued their denial, robbing him of the chance to respond.
Under ERISA regulations, insurance companies must provide claimants with a fair opportunity to respond to new medical evidence before issuing a final denial of an appeal. Specifically, ERISA requires insurers to disclose any new medical opinions, vocational reports, or other evidence developed during the appeal process and give the claimant a reasonable chance to review and rebut this information before a decision is made. The claimant’s response must be considered before issuing a long-term disability claim denial. This rule, a part of the “full and fair review,” ensures transparency and prevents claimants from being blindsided by unfavorable evidence they had no opportunity to challenge. Moreover, failure to comply with this requirement can be grounds for procedural violations, strengthening a claimant’s case in litigation.
Guardian’s failure to provide Mr. Sami a chance to review and respond to its new medical reviews robbed him of the chance to rebut their opinions. This is a per se violation of ERISA. In turn, however, it gave Mr. Sami the upper hand in litigation.
Why This Matters to You
ERISA claims are unlike other lawsuits. Courts often review the insurance company’s decision and focus on your claim file rather than any new evidence. This means the appeals process heavily depends on ensuring your record is complete and the procedures are fair.
In Mr. Sami’s case, his ability to highlight, and argue against, Guardian’s violations helped him get a fair shot at his LTD benefits. Without understanding the law and being able to spot ERISA violations, people may risk losing their chance to pursue their LTD benefits on technicalities.
The disability lawyers with Dabdoub Law Firm are experts in handling ERISA disability cases. We know what ERISA regulations require of the insurer, and of the claimant. We monitor all deadlines, pay attention to whether the insurance company has provided a full and fair review and have no reservation in filing a lawsuit for ERISA violations. All our lawyers have a full understanding of the law and are equipped to make sure the insurance companies conduct full and fair reviews as required by ERISA.
Why You Need an ERISA Long Term Disability Insurance Attorney
Navigating an ERISA long-term disability claim without a long-term disability attorney can feel like trying to solve a complex puzzle without all the pieces. Here’s how our law firm makes a difference:
- Understanding the Law
ERISA regulations are complex, and deadlines (both yours and the insurance companies) are strict. Our long-term disability lawyers ensure compliance with these rules and holds insurers accountable when they don’t.
- Building a Strong Record
Your claim file is the backbone of your case. Our long-term disability lawyers know how to gather strong evidence and challenge unfair practices, ensuring your case is properly presented. This includes building up a file full of medical evidence from treating providers, outside testing when appropriate, and non-medical evidence such as personal statements and vocational reviews.
- Maximizing Your Rights
Dabdoub Law Firm lawyers can identify procedural errors—like those in Mr. Sami’s case—and leverage them to strengthen your appeal. A blown deadline by the insurer can change the standard of the review applied by the court. ERISA regulations violations can weigh in your favor when making a claim a determination. Having an expert lawyer on your side will ensure these issues are spotted and an appeal or lawsuit is properly argued.
Conclusion
Mr. Sami’s case serves as an important reminder: protecting your ERISA rights requires diligence, strategy, and legal expertise. If you’re facing a benefits denial, don’t go it alone – hire Dabdoub Law Firm to protect your rights and ensure you get paid the max value of your claim. Hiring an experienced attorney can be the difference between a fair review and losing the benefits you deserve.
Our Lawyers Specialize in Disability Insurance Claims
Because our law firm has always focused only on disability insurance, our lawyers are experts in legal representation for disability insurance benefits.
That means our disability lawyers have:
- Won several major disability lawsuits that help make better law for disability claimants;
- Experience fighting every major insurance company, such as UNUM, Hartford, MetLife, CIGNA, Prudential, and more.
- Successfully represented hundreds of clients and won millions of dollars in disability benefits.
Because federal law applies to most disability insurance claims, we can help clients across the country.
Disability insurance companies have lawyers. You should too. Call Dabdoub Law Firm to get experienced disability lawyers on your side.
We can help with:
- Submitting a disability insurance claim;
- Appealing a long-term disability denial;
- negotiating a lump-sum settlement; or
- Filing a lawsuit against your disability insurance company.
Call for a free consultation with a disability attorney. No fees or costs until you get paid.
Keywords:
Condition: Chronic Pain
State: New York
Occupation: Senior Producer
Carrier: Life Insurance Company of North America