ERISA Disability and Life Insurance Litigation

How Does a Successful Appeal Lead to Reinstating Terminated Disability Benefits?

Ben Glass Episode 24

The Supreme Court has established a principle for cases challenging the denial of benefits under the Employee Retirement Income Security Act (ERISA). According to this principle, such denials should generally be examined anew (de novo) unless the benefits plan specifically grants the administrator or fiduciary the power to decide on eligibility for benefits or interpret the plan's terms.

The claimant, who worked as an Executive Sous Chef at the Hyatt Corporation in San Diego, California, started having symptoms of osteomyelitis, which is an infection in the spinal cord. Even after getting treatments like antibiotics and surgery, he still had a lot of pain because of the ongoing infection, degenerative disc disease in his lower back, and spinal stenosis. These health issues made him quit his job because he couldn't stand for long times, which his job required.

After over eleven years of receiving long-term disability (LTD) benefits, the claimant's payments were stopped by his insurance company, Hartford. The insurer decided that the claimant no longer met their criteria for being disabled. This conclusion was based on a functional capacity evaluation and the opinion of a medical professional who agreed with the evaluation's findings.

The claimant appealed the termination decision. He insisted that he was still considered disabled when the plan was terminated because he could not continuously work in any job that his education, training, or experience would have qualified him for.

This is the oral argument in the 4th circuit court of appeals

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Speaker 1:

And I don't get it. I don't get how somebody can be on a disability thing for 11 years and suddenly be okay, unless there's some good explanation for it. But it just obviously age can present health problems.

Speaker 2:

That youth does not Welcome to the podcast. This podcast is brought to you by Ben Glass Law, a personal injury and long-term disability law firm with headquarters in Fairfax, virginia. Listening to oral arguments is one of the best ways to both learn and stay abreast of the substantive and procedural aspects of practicing law. By putting these public domain recordings into the form of a podcast, ben Glass Law has made it easy for the public to access these recordings. All commentary that is not part of the actual court proceedings is that of the show's sponsor, the court.

Speaker 3:

My name is Glenn Cantor and I represent the appellant, Robert Shoup. Your honors, I'm here today because of what can only be characterized as a gross miscarriage of justice. In 2004, Mr Shoup, after having failed surgery and treated his horribly painful spinal disease of osteomyelitis, and after a failed attempt to return to his occupation as a chef, was deposed to go out on disability. He was paid benefits for 11 years. In 2016, after receiving benefits for 11 years, despite a deterioration in his condition, Hartford improperly terminated his benefits. If the record in this case is examined fully and fairly, it is literally impossible to find the termination of benefits based on the preponderance of the evidence and the record.

Speaker 4:

Cantor with regard, is there any other evidence against your client other than the Wolf FCE in all the 11 years?

Speaker 3:

No, your Honor. In fact I was prepared to go through the litany of the evidence where Hartford found again and again that he would not be returning to work.

Speaker 5:

Well you do Counsel, you do have Dr Lewis's report, so you've got Wolf and Lewis and those are the only contrary evidence to the other medical evidence. On Mr Shoup.

Speaker 3:

Yes, but Dr Lewis came after the denial so I thought Judge Boyd was speaking before the termination. Will I continue? Yes, please, yes. In order to take it all in context, I think you have to look at what occurred during the 11 years before the termination, Starting in 2004, Mr Shoup underwent no less than 25 interventional procedures in an attempt to alleviate his pain, including a surgery to decompress his spine, two separate spinal fusions, the implantation of a spinal stimulator and countless injections to relieve his pain. The procedures only stopped when his insurance was signed to authorizations and his doctors deemed there was nothing more that could do in the way of interventional procedures.

Speaker 5:

So what Counsel? What's our standard of review here?

Speaker 3:

It's de novo. Your Honor, the district court looked at this de novo, but it did it on summary judgment and my understanding of the Fourth Circuit law is you will review summary judgments de novo.

Speaker 5:

So do we owe any deference to the district court or, for that matter, to the Hartford's administrative review?

Speaker 3:

I believe, absolutely not. The district court's opinion, I think, is, to be honest, irrelevant to this matter. This court is looking at the facts de novo on its own and, with regard to Hartford, my take is that, given the facts, it should be given less than not only no deference, but it should have deference taken away because its credibility findings are so lacking. Any other questions on the review Senator? No, but I have a question about when he does when he takes a break from sitting.

Speaker 4:

What does he need to do to relieve the pain, and how long does that take?

Speaker 3:

I think that assumes facts, that there's no evidence that it will leave the pain. If you're speaking of the Dr Wolfe FCE that Hartford ordered prior to his termination, Dr Wolfe said he can sit for six hours a day, but what he said was the client speaking of Mr Shue should tolerate sitting on a constant basis at this time if permitted to stand, walk every 10 minutes to tolerance. So in other words, if he's going to sit, he can only sit for 10 minutes and then he has to get up and stand and walk until he feels better. We don't know what Dr Wolfe was thinking about, how long, but if you sit for 10 minutes and stand for 10 minutes, mathematically he has to work a 16-hour day to get eight hours of sitting work. It's a ludicrous proposition that Hartford took that report and said that's the reason he's denied, because he can sit for 10 minutes at a time.

Speaker 4:

There's also. I have one of the clerks do a calculation if we stick to the eight-hour day and six-hour sitting, those breaks are approximately three minutes each time. Is that enough?

Speaker 3:

Well, I don't think so. If you were to read Dr Wolfe's exit interview, after he spent several hours being tested, he says Mr Shue elected to rest on a treatment table upon completing the exam, in the supine and sideline positions for 20 minutes, mr Shue showed signs consistent with physical distress, including slow guarded movements, grimacing forward, flex posture, resting hands on knees and frequent weight shifting. At this time his pain after several hours of testing, one day of testing, not 40 hours in a week one day was seven out of 10. I'd remind the court this testing was done while on fentanyl.

Speaker 1:

Now, what medications counsel? What medications is he taking To dull the pain? Here there's mentioning that he was taking opioids. The masks the pain. Could you tell me what the medication regimen is?

Speaker 3:

Your Honor. At the start he was put on Vicodin. He was then raised up to morphine. That was back in 2006. They moved him to fentanyl. Fentanyl was the strongest drug he was put on. He was taken off because he was developing a tolerance, but he was eventually put back on At the time of the final termination. The IME performed by Dr Wolfach found that he was taking oxycontin and fentanyl and I think maybe Karma is helping my client here. I know your first case dealt with fentanyl and the courts are aware that it's only prescribed for intractable, intolerable pain. This is not a minor pain reliever. This man was in horrendous pain.

Speaker 1:

But he was taking pain medication the whole time, of one kind or another, and you say he was mainly a combination of fentanyl and morphine.

Speaker 3:

At the time that he was last tested, which was in 2016,. I can't say what he's taking today, of course, but yes, at that time, when he went through the FCE by Dr Wolf, hartford FCE he was on those narcotics and Dr Wolf said I think he could work, but I have to check into account that his pain could go up considerably if he didn't take the narcotics. And in your last case, judge Wolferson, you spoke about the real world. An employment assessment review was done by Hartford and they said first they cherry-picked the report because they only said six hours of sitting and ignored the 10 minutes at a time. But in the real world that we're talking about, we're talking about a man with a horrendously painful back disease who hasn't worked then for 11 years, who's taking narcotics, who can't use his hands, who has cognitive issues. Counsel, let me ask you about it.

Speaker 5:

Counsel. What are the effects? What does the record show as to the effects of the narcotics on Mr Shute, particularly as to his cognitive functions and his mobility?

Speaker 3:

As far as his cognitive function there are. I could give you the record sites. But in 2007, there were several different reports talking about the effects, his mental effects. The side effects of the medication were severe, that's at A167 and A1342. Once again in 2012, his doctor said that Shute had cognitive impairments from the medication. In 2015, his doctor again noted cognitive impairments from pain medication. This goes on.

Speaker 4:

How does that cognitive impairment define that for him? It wasn't. When you say he has a cognitive impairment, was that preventing from doing or causing?

Speaker 3:

Your Honor. There's nothing in the record that specifically identifies how it impacts him, other than to say there are cognitive impairments. There was no neuropsychological testing done because there was no point to it. He also couldn't sit and he couldn't use his hands. There was no testing done.

Speaker 3:

I think we have to go on the common sense approach. With somebody who's taking fentanyl and oxycontin is going to be impaired in his functionality Continuing during the 11-year period. I think we also should recognize that at the start of all this, hartford was so sure he wouldn't go back to work that they offered him assistance in obtaining Social Security. That assistance, of course, was successful. I think we all know it was not altruistic in the part of Hartford to assist Mr Shute because it reduced its financial obligation to him from $3,500 a month to about $1,900 a month. This court is well aware of the Supreme Court's view and this court's view of assisting and ensuring and obtaining Social Security benefits and then terminating the benefits with no meaningful change in the condition. In fact, when Hartford decided it had paid Mr Shute long enough and terminated his claim, it didn't give him a viable reason for why it averaged Social Security. Hartford advised Mr Shute that Social Security employs what it called a unique set of federal criteria, and it falsely advised him that, unlike Hartford, the Social Security Administration does not conduct an analysis of skills, maybe transferable or other occupations. That statement is blatantly false. As the court knows, when an SSDI claimant reaches the ALJ level, vocational experts are present at hearings to perform a transferable skills analysis.

Speaker 3:

As I've discussed at all times in over the 11 years and continuing, he was always on 24-7 constant narcotics to alleviate the spinal condition. There was nothing else that could be done to relieve his pain. I think it's important to note that, as I said again and again, hartford recognized he was not going to work. At one point he decided he wasn't going to back to work and valued his claim, according to its own notes, at $255,000. And so it offered him $157,000 to buy him out.

Speaker 3:

Now it's interesting if they value his claim at $255,000, why do they only offer him $127,000? Perhaps that's the conduct of a financially self-motivated insurance company and not producing? With regard to what happened at the time of the termination, as you say, hartford had three pieces of evidence. They had the WOLF FCE, which is, in my view, supportive of a finding disability. They had an employee-ability assessment review which is basically totally unreliable. It doesn't take into the real world and it also cherry-picks the report by failing to acknowledge that he could only sit or ten minutes at a time and couldn't use his hands. And Social Security has determined that for an unskilled sedentary position, a worker has to have use of his hands.

Speaker 1:

All right, thank you very much, mr Cantor. We appreciate it.

Speaker 6:

May it please the court. My name is Grace Murphy and I'm here today on behalf of Abilies and defendants for life and accident insurance company and the Hyatt Corporation disability plan. Judge Hilton district court decision correctly assessed the record as a whole and the totality of the evidence and applied for circuit law correctly and both striking plaintiffs post exhaustion submission and in affirming Hartford's claims decision With the four corners.

Speaker 5:

Do we judge Hilton's decision any difference?

Speaker 6:

No, your honor, as I understand it and I do concur with plaintiffs counsel that, as I understand that the standard review is to know those you will be looking at this with fresh eyes.

Speaker 1:

I just don't understand here why you don't have an abuse of discretion provision in your plan, because you would be view a whole lot more Deference if the plan read why do it seem like such an obvious step to take to have an abuse of discretion provision in your long term disability plan? But I couldn't find any.

Speaker 6:

Yes, your honor, the reason that the party is actually stipulated to do know those standard, review it. This policy was delivered in the state of Illinois. That's where Hyatt is headquartered and based. The plan is administered and they have a state discretionary ban. So even if there is discretionary language and I believe there may be but even if there was the operation of that statute we conceded resulted in application.

Speaker 1:

That's you to be talking about.

Speaker 6:

It is an Illinois state statute, your honor.

Speaker 1:

And then the joint appendix in our stipulation to know what a national insurance company, a plan and take cognizant fact that the abuse is not apply in the following states. And then you have Illinois be one of those states. But companies do this all the time. They say this is not applicable and I'm still perplexed as to why there's no use of discretion standards here because we're not dealing with Illinois.

Speaker 6:

Yes, your honor, I think that there is case law, the choice of law provisions. That policy says will be the policy will be construed under the state where the policy was delivered, which is Illinois in this case, and I understand the standard of review is is what it is, but we believe that the record here today still demonstrates that Hartford made the correct decision.

Speaker 1:

So let me ask you one other question about this. Normally, when people have the combination of ailments that this gentleman had over time, most people as they get older I hate to say this, but most people as they get older tend to go downhill or go maybe not improve. But here you're trying to say the person was on disability payments for over 11 years and what's? All of a sudden he's fine.

Speaker 2:

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Speaker 1:

And I don't get it. I don't get what how somebody can be on a disability payment for 11 years and suddenly be okay, unless there's some good explanation for it. But it just. Obviously age can present health problems that youth does not. And how does somebody just all of a sudden, after 11 years multiple surgeries, pain issues, limited use of the hands, taking opioids to mask the pain, sitting, standing restrictions and all of a sudden you say, oh, he's just fine. And I don't get it.

Speaker 6:

Your Honor, if I may, a couple of responses to that. This man was in his 30s when he first went out on claim. He had a surgery before awards were benefited. He then had surgeries in 2005 and 2006, and he had a spinal cord stimulator implanted in 2010. At that point, your Honor we're looking at six years later from that he was evidence of a slow and steady strengthening and stabilizing. He was at a and if you want to call it marginal improvement, if you want to call it a stabilizing there was a status blow at the time that Hartford was it is charged with continuing to look at claims. It cannot be. It is an erasive fiduciary. It would be a breach of that duty to award a claim and never touch a file again for the maximum payable period.

Speaker 5:

Council, let me ask you, other than the Wolf FCE and Dr Lewis's report, what's your best evidence to Mr Shue?

Speaker 6:

Your Honor. I think if you look at the narrative and the totality of the record to understand why the Wolf FCE was even suggested in the first place, I think you'll understand better the sequence of events. What happened was Mr Shue had not seen an orthopedic.

Speaker 5:

I have to tell you, having gone back through Mr Shue's medical record that's in our record both before the Wolf FCE and what was submitted afterwards Humbacker and somebody else, wood Wolcock there doesn't seem to be much ground there for Hartford to hang its hat on.

Speaker 6:

Your Honor. In August 2015, dr Robinson, who was planning his really only treating physician at that time of pain management, who was just monitoring there was no change in treatment, he was just monitoring his ongoing treatment submitted some restrictions and limitations in response to an attending physician statement and, taken together, it suggested that the plaintiff may have sedentary full-time capacity. So, in doing its due diligence, hartford reached out to Dr Robinson to say you've submitted these, we're looking at it. Would you agree that he has full-time sedentary capacity? Unbeknownst to Hartford, dr Robinson had actually left the practice and Dr Wittenberg had stepped in to take over patients' care. She was the one who said I cannot assess this without a functional capacity evaluation. So, in good faith, hartford then reached out and obtained the Wolf FCE, as we've discussed, and the Wolf FCE I think you need to look at as in its totality plaintiff has pointed to some things, but it was a full. It was from about 11.30 in the morning to 5.00 at night.

Speaker 5:

It spent a lot of time. Now I realize what the Wolf FCE says, but then a few months later you have the Humbacker examination, which doesn't do you all very much good.

Speaker 6:

Yes, your.

Speaker 5:

Honor, it just looks like the Wolf. Fce and Dr Lewis's report are somewhat outliers in the long history of disability.

Speaker 6:

Your Honor respectfully, I would disagree with that characterization. I think once the Wolf FCE came they actually sent back to Dr Wittenberg, his pain management physician, and said please take a look at this and see if you agree. Please call us if you want to discuss. Here's some blanks to fill in. And she checked. Unequivocally I agree with the conclusions. Plaintiff has full-time sedentary capacity. That is when Hartford then did its employability analysis and there were jobs that allowed him, and I think Plaintiff's Council has misread the FCE by saying he was actually required to stand up every 10 minutes. It's suggested he was required to shift positions with tolerance. He was observed actually during the FCE sitting for 95 minutes with some positional changes in another 45-minute period, and so the jobs that we identified as representatives allowed for those positional changes.

Speaker 4:

Let me ask you this, ms Murphy these jobs like assignment clerk, jacket preparer, batch records clerk, can they be done by somebody whose own drug, such as fentanyl, your Honor.

Speaker 6:

On the question of his any impairments from cognitive impairments, I don't. Plaintiff's Council testified that there was no need to do neuropsychological testing. I disagree with that. There is no real evidence of the extent of it. He was on his pain medication during the time of the FCE and what Ms Wolfe said is that if he wasn't, maybe his pain would be increased. But what she did not say was that the pain medication affected his ability to do those activities in any way.

Speaker 1:

I could not affect his ability. I don't understand that.

Speaker 6:

Your Honor, it is Plaintiff's burden to prove establishment. There is doctor his own doctor, robinson, in 2014 indicated that there were no cognitive impairments that Plaintiff suffered At times. He said there were some cognitive impairments, but the question of whether his was cognitively impaired. Plaintiff has never been able to demonstrate that is true and he has been able to engage in certain physical activities that he's been seen doing. He's lived on this pain medication for many years. He has reached a status quo.

Speaker 5:

If he'd gone on for all these years on the basis of disability because he can't sit, why would they need to also go into cognitive impairment at that time? If he was disabled purely on his physical inability to function, there's no legal requirement that he show. Alternatively, a cognitive impairment is there.

Speaker 6:

Your Honor. I believe there is an obligation on him to demonstrate the full extent of his disability. The physical requirements he was his own doctors in fall of 2015 into early 2016 were saying he had the physical sedentary capacity. He had 240 days to appeal the case, while he had a vocational assessment that mentioned medication impairments could. They were all very speculative and there was no pinpoint evidence that he himself experienced side effects from medication that prevented him from working in a full-time sedentary capacity in the sample occupations or otherwise that have been identified.

Speaker 1:

You say that he is stabilized at a certain point over this period, but did Hartford actually believe that you continue to provide him disability, doesn't it? Over a long period of time, including a period of time in which you said he had stabilized, but you still regarded him as disabled?

Speaker 6:

Your Honor, we deferred, we listened to his treating physicians. In 2013, there was an FCE that showed that he was not conditioned to return to work. It did not say he was the main findings of that or that he was physically deconditioned. So at that point, we, in good faith, continued to pay benefits allowing him additional time and, as he was observed and self-reported, his physical activities increased. At that point, he was out repairing car stereos, he was driving, he was taking family members to medical appointments, he was out and about and so, when we continued to ask for as it was our duty and requirement to ask his doctors for their medical opinion on his functionality, when those, as of 2015, show that he at that point likely had sedentary capacity, hartford went to the next step in trying to get his attending physician to speak to whether that was, and that's what triggered the FCE in 2016 that demonstrated the full-time sedentary capacity.

Speaker 6:

Your Honor, there's some policy provisions here that I think we need to look at that are the speak to the concerns of the sport. One is that the policy itself includes continuing proof of disability calls, which provides that a claimant maybe has to submit proof that he continues to be disabled and he must provide it within 30 days or risk delay, suspension or termination of benefits. Also, the proof of disability language in this policy includes an objective medical findings requirement that they must produce test procedures or clinical examination standardly accepted in the practice of medicine for his disabling condition. The last objective medical test was a 2015 CT scan. At that point, and again in this trajectory of this claim, he was not going to be undergoing any more orthopedic treatments. He was living his life as he had with chronic pain.

Speaker 6:

That is the Gallagher case has shown. Chronic pain in and of itself is not enough to establish a disability. You must find that the chronic plaintiff must meet his burden of showing that chronic pain is prevents him from performing all occupations. In this case, in the Gallagher case, indeed, it said that whether Gallagher's pain made him totally disabled, however, hinges on whether it made him incapable of performing all the duties of his occupation. In that case, the insurer had shown that there was marginal improvement, but there was no objectively satisfactory proof that he was disabled. We suggest that the same applies here at this case.

Speaker 5:

So Council just go ahead, Judge Wilkerson.

Speaker 1:

I just want to know how many spinal surgeries this individual had. Back surgery is always a little tricky work. How many surgeries on his spine did he have over this period?

Speaker 6:

Before he filed the claim he had one and then, as I understand it, he had two, but the last one was in 2006, 10 years before benefits were terminated. He had a spinal stimulator implant in 2010. I'm not sure that counts as a true spinal fusion, but I did want to mention that too.

Speaker 5:

Well, just assuming for purposes of argument, if we were to agree with plaintiff's counsel that the district court ruling was erroneous, what do you say would be the relief that should be granted?

Speaker 6:

Your Honor. I think that the relief that would be granted is depending on how the opinion comes down. I believe one of the options would be an award of pastive benefits and a remand to Hartford to continue looking at this claim. This claim was terminated again in 2016. There can be no award of future benefits after that time and there needs to be a review of this claim.

Speaker 6:

It depends if this court finds that there was some piece of evidence that was missing, or that plaintiff submitted and we didn't review or something to that extent, and it can also remand with no award of pastive benefits and just ask that Hartford take another look.

Speaker 5:

So, but I guess what I'm asking is, if we were to find for the plaintiff here, do we simply vacate and return to the district court for further proceedings, or do we vacate and return it to the district court with instructions?

Speaker 6:

I have seen it done both ways, your Honor, and I think you have the leeway to do either one in the unfortunate event that you come down that way.

Speaker 1:

I'm just wondering what further proceedings would there be. It seems to me the record is you go one way or another on the record and I'm just not sure the polls and the record there are, or what further medical reports there would be, whatever. I don't know, I'm just not sure what needs to be done. We've got a record and might just have to take the call one way or the other.

Speaker 6:

Well, your Honor, we haven't discussed the ruling on the motion to strike at this time. Assuming that ruling stands and that plaintiff's post exhaustion submission does not come in, then the record would be complete if there is some inclination, and I would appreciate the opportunity to argue against that. But if that evidence from May 2017 does come in, then a remand would be more appropriate.

Speaker 1:

All right, anything further? Ms Murphy, I guess your time is pretty close to expired.

Speaker 4:

No, your honor thank you.

Speaker 1:

We thank you, mr Cantor, some time for?

Speaker 4:

Thank you your honor that Asked that motion to strike on this record. Do you need that evidence in the record?

Speaker 3:

No, are you okay? How? I don't need it. I think it was an error to exclude it under prison very first. I have the Utmost and highest respect my opposing counsel. I think she's an incredible lawyer. I do have to disagree with her statement, though, about that May letter from dr Wittenberg where she characterizes a. Dr Wittenberg agrees with the conclusion that he can return to work. There's nothing in the wolf report that says he can return to work. All she said was that she agrees with the findings, and the findings were he would only be able to sit for 10 minutes. Given the ambiguity of the wolf report and Dr Wittenberg seeking to clarify what she was saying, that she thinks he's still fully disabled, I would think that Any court looking at this de novo would want clarification of what she meant. But I don't need it to come in Following that, so count counsel.

Speaker 5:

if we were to find in favor of mr Shoe, what do you say is the relief that should be granted?

Speaker 3:

I think the first thing is Murphy said, which was Benefits paid to date and a reinstatement of the plan for Hartford to further administer it. I agree you can't order future benefits. We didn't ask for that. I think we should remember. Before mr Shoe Stopped working, he was earning close to six thousand dollars a month. When he goes out in disability he drops to 3,500. When he's cut off by Hartford all he has left is Social Security, about 1100 dollars a month. For the past five years he's been living on 1100 dollars a month when he should have been getting 3500. The axiom that justice delayed is justice denied is applicable here. This court, in my humble opinion, should find that he's entitled to benefits and direct the district court To order benefits reinstated.

Speaker 1:

Is there anything further, mr Cantrell?

Speaker 3:

just a point that might interest you judge workers and welcome said. I'm sorry, but you asked about the abuse of discretion. I would point out that Mr Shoe, at the time he was employed, was working in California. California has a ban on discretionary provisions. If you're talking about the state in which the insured was employed, it was not Virginia, it was California. The case was filed in California and Hartford moved to transfer to Virginia because that's where he was residing at the time of the Denhouse.

Speaker 1:

So is it the California ban that's applicable.

Speaker 3:

No, could be the California ban, but I think more appropriately, it is the Illinois ban. But if the Illinois ban applies to the state in which you're residing, who was residing in California? But the Illinois ban prohibits discretionary clauses to be included in group policies issued in the state of Illinois, which this policy was.

Speaker 1:

All right, thank you, is that? Do you have any further?

Speaker 5:

No, sir, no, I don't.

Speaker 3:

Thank you your honor.

Speaker 1:

If there's no further question. I want to thank you both. Can't come down and shake your hands. That we're very appreciative of, oh, the arguments that both of you have made. Hope you have a nice afternoon.

Speaker 3:

Thank you, your honor.

Speaker 1:

I'll ask the courtroom To adjourn court.

Speaker 3:

Sign a die this honorable court stands adjourned until this afternoon. God save the United States in this honorable court.

Speaker 2:

The proceeding has been a production of Ben Glass law, a fairfax, virginia based personal injury and long-term disability law firm. For a free evaluation of your claim, visit us at Ben glass law calm or call us at 703 591 9829.