How Disability Carriers Manufacture Reasons to Deny Claims

Welcome to Season 6, Episode 12 of Winning Isn't Easy. In this episode, we'll dive into How Disability Carriers Manufacture Reasons to Deny Claims.

Imagine qualifying for Long-Term Disability benefits, only to have your insurer cite a vacation, a college class, or a game of pickleball as proof you can still work. Surveillance footage, social media posts, and selective medical reviews can quickly become the basis for a denial you never saw coming. ERISA disability claims often turn less on diagnoses or surgeries and more on how insurers interpret daily activities, medical records, and how “stable” a condition appears on paper. Routine moments of normal life can be reframed as evidence of employability, while peer reviews, surveillance, and insurer-friendly standards of review are used to justify terminating benefits. In this episode, we explore how everyday activities are weaponized against claimants, how medical stability is reinterpreted to argue work capacity, and why courts sometimes uphold these denials despite serious medical conditions. If you’re navigating - or trying to protect - an ERISA disability claim, this episode explains why careful documentation, precision, and strategy can make all the difference.

In this episode, we'll cover the following topics:

One - Can Taking an African Safari, Attending College Classes, and Playing Pickleball Destroy Your ERISA Long-Term Disability Claim?

Two - How a Hartford ERISA Disability Claim for Rheumatoid Arthritis and Spine Surgery Played Out at the Any Occupation Stage of the Claim

Three - Is Discovery Allowed in an ERISA Disability Claim When the Carrier or Plan Has Created Reasons to Deny Your Claim?

Whether you're a claimant, or simply seeking valuable insights into the disability claims landscape, this episode provides essential guidance to help you succeed in your journey. Don't miss it.


Listen to Our Sister Podcast:

We have a sister podcast - Winning Isn't Easy: Navigating Your Social Security Disability Claim. Give it a listen: https://wiessdpodcast.buzzsprout.com/


Resources Mentioned in This Episode:

LINK TO ROBBED OF YOUR PEACE OF MIND: https://mailchi.mp/caveylaw/ltd-robbed-of-your-piece-of-mind

LINK TO THE DISABILITY INSURANCE CLAIM SURVIVAL GUIDE FOR PROFESSIONALS: https://mailchi.mp/caveylaw/professionals-guide-to-ltd-benefits

FREE CONSULT LINK: https://caveylaw.com/contact-us/


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Need help with your Long-Term Disability or ERISA claim? Have questions? Please feel welcome to reach out to use for a FREE consultation. Just mention you listened to our podcast.

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Please remember that the content shared is for informational purposes only, and should not replace personalized legal advice or guidance from qualified professionals.

Transcript

Nancy Cavey [00:00:15]:
 Imagine qualifying for your long term disability benefits only to have your disability insurance carrier plan point to a vacation, a college class, or even a game of pickleball as proof that you can still work. Surveillance footage, social media posts and cherry picked medical records can suddenly become the foundation for a claims denial or termination that you never saw coming. Hey, I'm Nancy Cavey, national ERISA and individual disability attorney, and I want to welcome you to Winning Isn't Easy. Before we get started, I have to give you a legal disclaimer. This podcast isn't legal advice. The Florida Bar association says I have to tell you this. And now that I've told you this, nothing will ever prevent me from giving you an easy to understand overview of the disability insurance world, the games that disability carriers play, and what you need to know to get the disability benefits you deserve. So off we go now.
 
 Nancy Cavey [00:01:11]:
 ERISA disability claims are not decided solely by a diagnosis or surgeries. They are decided ultimately by how a disability carrier plan will interpret your daily activities, your medical records, and even how how well managed your medical condition appears to be on paper. Carriers will routinely manufacture both medical and vocational justifications to terminate benefits, and they'll rely on surveillance, liar for hire, peer review reports, and a very restrictive standard over review that will favor denial over fairness. In this episode, I'm going to talk about how everyday activities can be weaponized as and how insurance companies or plans will reinterpret medical stability to argue employability, and why courts will often uphold these denials despite serious medical conditions. If you're navigating an ERISA disability claim or trying to protect your claim, this episode will explain why precision, documentation and strategy are everything. So let's dive in. I'm going to talk about three things. First, can taking an African safari, attending college classes and playing pickleball destroy your ERISA long term disability claim? 2.
 
 Nancy Cavey [00:02:28]:
 How a Hartford ERISA disability claim for rheumatoid arthritis and spine surgery played out at any occupation stage of the claim. And lastly, is discovery allowed in an ERISA disability claim where the carrier plan has created some reason to deny or terminate your benefits? Got it. Let's take a quick break for a moment before we get into this episode.
 
 Speaker B [00:02:52]:
 Have you been robbed of your peace of mind by your disability insurance carrier? You owe it to yourself to get a copy of Robbed of your Peace of Mind, which provides you with everything you need to know about the long term disability claims process. Request your free copy of the book@kvlaw.com today.
 
 Nancy Cavey [00:03:12]:
 Foreign. Welcome back to Winning Isn't Easy can taking an African safari, attending college classes and playing pickleball destroy your ERISA long term disability claim? Well, I think you already know the answer to that question, don't you? But let me tell you this story. The senior vice president of corporate development for Sonata Pharmaceuticals, Stephen Bernitz, became disabled as a result of chronic low back pain. And for years he collected disability insurance benefits from US abled life. However, in December of 2019, they determined that he had experienced significant improvement based on him taking an African safari, attending college classes and playing pickleball and said, well, if you can do these things, you could do your work as a senior vice president. So what do you think he did? He filed an appeal which was denied and of course his case ends up in federal court. Now, the court concludes that this activity, which also included working out with a private trainer and walking up to half a mile a day, was not inconsistent with his job duties. He could meet the sitting, standing, walking, typing and travel requirements.
 
 Nancy Cavey [00:04:29]:
 And guess what? Didn't help. The surveillance didn't help. So what are the kinds of lessons that you can learn? Well, just because the disability carrier plan accepts your claim doesn't mean that they're going to continue to pay your benefits every month and for the life of your benefits. Secondly, the disability carrier plan is going to review your medical records closely looking for any improvement. And the disability carrier will guaranteed review your social media accounts. And of course, and ultimately depending on what they find in the medical records and in your social media accounts, they're going to add the surveillance to this suit, if you will. They're going to check on your activities based on what it is you said you could do in terms of your activity of daily living forms, your medical records, what the social media accounts say and what's verified or not verified by surveillance. The bottom line here is that you really shouldn't be doing anything that's inconsistent with your claimed disability.
 
 Nancy Cavey [00:05:29]:
 For example, part of his job duties were to travel and if you can travel to Africa to go on a safari, that's problematic, isn't it? Understand that the disability carrier plan is going to jump on any reason they can to deny or terminate a claim. So don't give them any reason to deny a claim. Got it. Let's take a break. Welcome back to Winning Isn't Easy. Let's talk about how a Hartford ERISA disability claim for rheumatoid arthritis and spine surgery played out at the any occupation stage of a claim. Now, one would think that having undergone multiple spine surgeries would automatically qualify you for Your ERISA disability benefits. Sprinkle in some rheumatoid arthritis and you would think that that's icing on the disability cake.
 
 Nancy Cavey [00:06:29]:
 But what happens if your doctor's treatment plans indicate that your pain is well managed, whatever that word might mean. Now, in 2018, Mr. Coley began experiencing neck and shoulder pain from rheumatoid arthritis. He underwent the first of three spine surgeries. He applied for and was paid his own occupation benefits until the definition of disability changed after 24 months to the inability to do any occupation. Now, Hartford Life then turned on its claim termination machine and they had his file reviewed by his liar for hire peer review providers and required him to undergo a not so independent medical evaluation. Guess what they concluded. Although Cooley's condition was serious, it was well managed by his physicians and the treatment plan.
 
 Nancy Cavey [00:07:24]:
 And while he had certain restrictions and limitations, he could work a 40 hour workweek. Now, in arriving ultimately at the decision, the disability carrier, as I have said, turned on their termination game plan, if you will. And ultimately the court ends up reviewing this denial using something called the arbitrary and capricious standard of review. There are two standards of review in an ERISA disability case. First is the arbitrary and capricious standard of review. Now, I only wish that those words meant what they sound like they mean, and in the context of an ERISA disability case, they don't. And I'll explain why in a second. The other standard of review is what's called a de novo standard of review where the judge gets to substitute their judgment for the judgment of the disability carrier or plan.
 
 Nancy Cavey [00:08:17]:
 Now, ultimately, the court upholds the denial benefits, holding that there was substantial evidence to support Hartford's termination of benefits and their determination that he could do other work. So what were the lessons learned? Well, first off, there was this not so independent medical evaluation report that indicated that he had essentially, quote, unquote, normal examination findings and that his pain was well controlled. The IME doctor opined that the claimant could work and had certain restrictions and limitations, but nonetheless could do a 40 hour work week. The problem here, I think, was the word well managed. There was no definition of well managed in the plan or policy, and there was no definition of well managed in terms of what the IME provider had to say. And I think that that was a problem because there are practice guidelines based on different types of injuries and medical conditions that establish the nature of the treatment plan that should be applied. And there are also other factors that need to go into the determination of whether that treatment plan is being followed and the result of that treatment plan. What I would have done, and I've been representing him, was to ask the disability insurance carrier plan to provide us with any and all documentation that is established with the definition of well management.
 
 Nancy Cavey [00:09:57]:
 Whether they were applying various treatment plan criteria or criteria that can be used to determine how long it will take for a person to recover and potentially what the complications are. We want to understand the internal thought process in quotes that the disability carrier was using. I would have next gone back to the treating physician and after we had had what's called a functional capacity evaluation to address in fact this person's tolerance for work, I would have addressed with my client side effects of medication and how those side effects impacted their ability to function. I also would have talked to my client about flares. Were there times that activity such as sitting, standing, walking, lifting may have resulted in flares that would have made this person unable to work. And then ultimately I would have taken all that back to the treating physician and asked for their comment. And if that didn't work, we would have hired our own independent medical evaluator to address those issues and to take on the disability carriers. IME doctor's opinion that the condition was quote, unquote, well managed.
 
 Nancy Cavey [00:11:19]:
 Well managed does not necessarily mean that one can work. You can be well managed and still in significant pain and dysfunction. So I think it's really key that you take apart what that word term, well managed means, what it means in the context of each one of the disabling medical conditions and attack it head on with, as I said, more information about the nature of well managed flares, side effects of medications, the increased activity and how it would impact a person's ability to work and have that all wrapped up in a package with a functional capacity evaluation endorsed by the treating physician or our IME physician. You can see that details and strategy do matter. Got it. Let's take a break.
 
 Speaker B [00:12:09]:
 Are you a professional with questions about your individual disability policy? You need the Disability Insurance Claim Survival Guide for Professionals. This book gives you a comprehensive understanding of your disability policy with tips and to dos that will assist you in submitting a winning disability application. This is one you don't want to miss. For the next 24 hours, we are giving away free copies of the Disability Insurance Claim Survival Guide for Professionals. Order yours today@disabilityclaimsforprofessionals.com.
 
 Nancy Cavey [00:12:48]:
 Welcome back to Winning Isn't Easy. Is discovery allowed in an ERISA disability claim when the carrier or plan has created reasons to deny or terminate your benefits? I Want to give you an example of how disability carriers or plans create medical and vocational reasons to deny a claim. And this is based on a reported case of Digeronimo v. UnumLife. It's a case out of Ohio in August of 2025. I think that we could always learn lessons from these cases that will teach us what to do and what not to do. Let me tell you the story. In September of 2024, Mr.
 
 Nancy Cavey [00:13:27]:
 DiGeronimo, who was employed by Independent Independence Excavating, began treating for epilepsy and had a right temporal lobe resection in 2006. In 2020, he applied for his long term disability benefits through Unum. He submitted his medical records and supporting letters to his disability carrier, material from his physicians. Now, Unum used its cast of characters, those liar for hire doctors that were we see every day, to create reasons to reject the opinions of his treating physicians that his seizure disorder was stable. Now as part of the appeal, he even submitted the report of a vocational rehabilitation counselor who agreed that he could not perform his occupational duties because his post seizure recovery periods would last 24 to 48 months, hours rather, and he would have fatigue, lethargy and confusion. And of course that didn't persuade UNUM to change their positions. And ultimately digeronimo filed a lawsuit in federal court and he sought discovery about the basis of the liar for hire's opinions. So let's talk about discovery.
 
 Nancy Cavey [00:14:39]:
 If you've been watching the news, you have heard about various subpoenas being issued and testimony and depositions being taken in the context of all sorts of litigation. Now, discovery is governed in an ERISA case under the Federal Rules of Civil Procedure. And it allows discovery regarding any non privileged matter that is relevant to a party's claim or defense and is proportional to the needs of the case. That's Federal Rule of Civil Procedure 26. Now, the ERISA statute does not talk about discovery. So federal courts have taken up the issue of whether there is discovery and if so, the extent of the discovery. And there is conflict between the federal circuits in the United States about what's allowed or not allowed as a matter of practicality, if you will. Federal courts across the country have ruled that policyholders and plan beneficiaries really aren't entitled to discovery beyond what's called the administrative record, which is the claims file.
 
 Nancy Cavey [00:15:47]:
 There are some exceptions, but that's not the rule. The administrative record is what is contained in the carrier plans file when the appeal process ends. And unfortunately for many, they learn too late that the appeal is the trial of their case, which is crucial and a good great reason why you shouldn't be writing and submitting your own appeal. And you should be hiring an experienced risk disability attorney. They're going to ensure that they've got the claims filed, that the claims file is complete, and they're going to address every blasted reason why the carrier plan denied or terminated benefits. Now, in our case, our Appeal letters are 25 to 65 pages long and they're full of medical, legal and vocational information that attacks and rebuts the reasons why the carrier or plan denied or terminated benefits. But to be entitled to discovery in an ERISA case, the ERISA claimant has to provide evidence of bias or procedural irregularities to justify the discovery. Now having to provide that evidence of bias before you get discovery is, in my opinion, fast backwards.
 
 Nancy Cavey [00:16:54]:
 The mere allegation of bias is not generally enough to throw open the doors of discovery. Now that can make the burden difficult, if not impossible to meet. But there are some evidence of bias that's been developed in individual disability claims against Unum, and those are state claims. And in the estate claim discovery is allowed. So in this Deronomo case, he propounded a number of what's called interrogatories, which are questions and requests for production of documents, and asked to be allowed to depose any medical or vocational reviewers identified in the interrogatory responses. Of course, he wanted to know the identity of the people involved in the claim, including those offering opinions, information about other unrelated claims from the past five years involving epilepsy or recurrent seizures, the CVs of any persons or vendors involved in deciding the claim or rendering opinions, and detailed information about Dr. Scott Norris, who is widely used as a peer reviewed disability provider by carriers and plants now did attempted to justify these requests based on the inherent conflict in Unum's role both as the decider and the payer of the benefits. It should be noted that Dr.
 
 Nancy Cavey [00:18:13]:
 Norris has been involved in at least 40 district cases where his opinions have been criticized as conclusory and not borne out by objective evidence or even cherry picking the evidence. Now in this case, the court found that that request for discovery was a fishing expedition and denied them. I think that this is wrong for lots of reasons and again, it really depends in part on the circuit that you're in, because there is some discovery decided generally on a case by case basis. But this approach to no or limited discovery does nothing but encourage carriers to manufacture reasons to to justify claims, denials or terminations, knowing that they can use the same liar for hires without penalty. Now we know based on discovery and individual disability claims that there are quotas, there are bonuses paid, there are even parties that they throw for meeting their goals of denial or termination. And we also know that every disability carrier plan has profitability goals. And guess how they meet those goals? By denying or terminating benefits. We can only hope one day, hopefully in my lifetime, where Congress says enough and changes the ERISA statute to allow for what's called a de novo standard of review where the judge gets to decide and allows discovery to stop.
 
 Nancy Cavey [00:19:36]:
 In essence, these predatory techniques that break the very promise the disability carriers are planning make to you when they offer you the disability coverage. Now that wraps up today's episode of Winning Isn't Easy. Thank you for tuning in. If you found this episode helpful, please take a moment to like our page, leave a review, share it with your family and friends, and of course, subscribe to our podcast. Join us next week for another insightful discussion. An episode of Winning Isn't Easy. Thanks for listening, Sam.