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The Standard Disability Denial Reversed

The case involves a client who was a managing director of a tax department, a cognitively demanding role requiring precision with financial data. He purchased an individual disability policy through an agent with Standard Insurance, independent of his employer, and paid the premiums himself. Individual policies typically have a lower denial rate compared to employer-provided group policies due to differing legal frameworks, but his claim was denied upon initial application. His disability stemmed from a January 2022 COVID-19 infection that exacerbated or triggered multiple conditions, including chronic fatigue syndrome, fibromyalgia, ADHD, insomnia, and other sleep issues. These conditions progressively worsened, making it impossible for him to continue working.

Standard Insurance conducted a thorough review, more comprehensive than many larger insurers, including a two-day Independent Medical Examination (IME) with a neuropsychologist and file reviews by a rheumatologist and an internal medicine doctor. The neuropsychologist questioned the validity, effort, and consistency of the client’s performance, suggesting the results were unreliable. The file reviews challenged the chronic fatigue syndrome diagnosis, asserting there was insufficient evidence to support his subjective complaints, leading to the denial of his claim.

Attorney Stephen Jessup developed a strategic appeal to overturn the denial, focusing on objectifying the client’s subjective symptoms. Key steps included:

• Obtaining Standard’s complete claim file, including all review reports, which, while not legally required for individual policies, Standard provided, allowing a detailed analysis of their rationale.
• Arranging a Functional Capacity Evaluation (FCE) to assess the client’s ability to perform sedentary work, the physical baseline for his job. Jessup instructed the client not to rest before the exam to reflect his typical condition at the end of a workweek. The FCE revealed significant fatigue, supported by biometric data like heart rate and breathing, confirming he lacked the capacity for full-time sedentary work.
• Challenging the neuropsychologist’s IME report by providing research and reports demonstrating that chronic fatigue syndrome does not typically present with a neurological basis, countering the reviewer’s attempt to frame it as a neurological condition. Jessup also highlighted inaccuracies, such as the neuropsychologist’s claim that ADHD was not documented, when it was present in the medical records.
• Undermining the peer reviews by referencing CDC criteria for chronic fatigue syndrome, showing the client’s medical records met these standards, thus validating the diagnosis.
• Securing strong support from the client’s treating physician in Idaho, who provided detailed statements and forms refuting Standard’s dismissal of the diagnosis and symptoms.

The appeal emphasized the cognitive demands of the client’s tax director role, arguing that even if he could manage activities of daily living, the mental rigor required for his job was unattainable given his fatigue and concentration issues. Jessup’s comprehensive approach, combining the FCE, medical research, physician support, and direct challenges to the IME and peer reviews, convinced Standard to reverse the denial. The client received a back payment for benefits owed and had his benefits reinstated.

The attorneys noted that Standard’s thorough initial review, including an IME, made the appeal more challenging, as the company had a seemingly rational basis for denial. However, the victory demonstrates that Standard can be persuaded to reverse denials when presented with robust, objective evidence tailored to the claim. This case offers hope for claimants with subjective conditions like chronic fatigue syndrome, particularly when exacerbated by long COVID, showing that well-crafted appeals can succeed even against rigorous insurers. Jessup will continue to manage the claim, ensuring updated medical records and physician statements to prevent future denials, especially given the high cognitive demands of the client’s occupation.