Hartford Insurance Company Denied Disability Claim by PreSchool Teacher Based on Faulty and Dishonest Policy
We are currently helping a preschool teacher get long-term disability benefits that were denied to her based on faulty and dishonest policy interpretation by the Hartford Insurance Company and we fully expect to get her the benefits she deserves.
If you are or were insured for disability by Hartford under a disability insurance policy and you were given a definition of “Any Occupation” but you had a professional job or extensive experience and training in the job, we want to talk to you. Call us immediately at 855-837-5333.
The ERISA Law Center is representing Loretta Bruce in a pending lawsuit against Hartford Life and Accident Insurance Company. Hartford used Dr. Mark O. Bernhard, whose main office is in Pasadena, California and who has satellite offices throughout the state, to conduct an independent medical examination of Ms. Bruce. Hartford used the report from Dr. Bernhard’s medical examination to terminate Ms. Bruce’s disability benefits.
Dr. Bernhard has a record of fraud. Dr. Bernhard has a public record of discipline by the California Division of Worker’s Compensation Medical Unit’s Administrative Director; his QME status was suspended for six months, and he was placed on probation from 10/1/2011 through 4/15/2012, and was required to pay $5,916.25 in restitution. Dr. Bernhard was accused of over-billing, among other things, for 12 medical-legal evaluations conducted in 2010.
The Accusation contained seventeen causes of action for over-billing and billing fraud. The Accusation states that “[i]n submitting medical legal reports misrepresenting the amount of face-to-face time spent with at least one of these insured workers, and in billing claims administrator in excessive amounts based on such misrepresentations, Respondent violated material statutory prohibitions under Business and Professions Code §2234(e), Labor Code §5307.6(d) and Penal Code §550(b)(2) , and therefore, under Labor Code §139.2(k) and 8 CCR §§60 and 65, is subject to discipline up to and including revocation of QME certification.”
In each instance Dr. Bernhard billed an insurance company for more hours of “face to face time alone” with the patient, than he actually was with the patient. Pursuant to a stipulated settlement, Dr. Bernhard’s QME status was to be suspended for three months, he was to be placed on probation for six months, and was also required to pay $5,916.25 in restitution to the insurance companies and claims administrators who hired him.
Hartford certainly knows that Dr. Bernhard has a record of fraud – our office has informed them of this. We’re not clear why Hartford chooses rely upon Dr. Bernhard’s reports under these circumstances. We believe that Hartford Life and Accident Insurance Company uses Dr. Mark O. Bernhard to conduct independent medical examinations of disability claimants because it is confident that Dr. Bernhard will write reports that Hartford can use to terminate or deny disability benefits.
Has Hartford terminated or denied your disability benefits based on a medical examination and report by Dr. Mark O. Bernhard? If so, please contact our office at 855-837-5333.
Hartford Improperly Reduces Disability Benefits By Averaging Claimants’ Monthly Income
Hartford Life and Accident Insurance Company has different language in different policies regarding how to calculate a claimant’s monthly earnings. Many Hartford policies state that Hartford will determine the claimant’s monthly income (and thus benefits) by taking an average of income over a period of time – usually 12 months. When the Hartford policy states that benefits amounts will be calculated by averaging income, then doing so is proper.
However, other Hartford policies do not state that benefit amounts will be calculated by averaging. We represent Loretta Bruce in a claim for disability benefits. Ms. Bruce’s policy makes no reference to determining her benefits by averaging her income over a period of months. In her policy “Pre-disability earnings” is defined as “your Monthly Rate of Basic Earnings in effect on the day before you became disabled.”
“Monthly Rate of Basic Earnings” means your regular monthly rate of pay from the employer just prior to the date you became disabled (including contributions made to certain salary reduction agreements, but not including bonuses, commissions, overtime paid or expenses reimbursement).
When Hartford initially paid benefits to Ms. Bruce it did so based on her regular monthly rate of pay. After Hartford terminated Ms. Bruce’s benefits and reinstated them, it again paid her benefits based upon her regular monthly rate of pay. But later Hartford claimed that it overpaid Ms. Bruce’s benefits.
Ms. Bruce was a pre-school teacher. She worked nine months out of the year, not 12 months out of the year. Hartford later claimed it should have averaged her annual income over the course of 12 months to determine her monthly income and thus monthly benefits. As the policy language quoted above indicates, there is nothing in the policy that supports that interpretation. But based upon that interpretation, Hartford claimed that it overpaid Ms. Bruce by $26,205.84, based on the 24 months benefits it paid her.
In our opinion Hartford’s claim that it has overpaid Ms. Bruce is inconsistent with the policy, dishonest, in bad faith and fraudulent.
If you are receiving or have received disability benefits from Hartford based on a policy that has no reference to calculating benefits by averaging income over time and if Hartford reduced your benefits by averaging your income over time (because you worked, for example, in a seasonal job such as teacher in which you did not work 12 months out of the year), please contact our office immediately at 855-837-5333.
Hartford Life And Accident Insurance Company Misapplies The Definition Of “Your Occupation” In Certain Of Its Disability Policies.
Hartford Life and Accident Insurance Company issues many disability policies. Some explicitly state that when evaluating whether or not a claimant is disabled under his or her own occupation – “Your Occupation” or “Your Usual Occupation” – Hartford will consider the person’s occupation as it is performed in the national economy. Those policies define “own occupation” as “your occupation as it recognized in a general work place.
Your occupation does not mean that specific job you are performing for a specific employer or a specific location.” That is, Hartford will consider not what you actually did, but how people in general do your job. Under that definition even it you cannot do the duties of your own job, you might not be entitled to benefits under a Hartford policy if you can do the duties in general required of your job by other employers.
But Hartford also issues policies which do not include the “national economy” language. These policies are only issued to employers in California and so apply primarily to California residents (and also to residents of other states whose employers had policies issued to them in California).
Our client, Loretta Bruce, was insured under a policy issued to a California employer. Her policy states nothing about how her job was done in the national economy. Her policy states:
Disability is defined as: “during the Elimination Period and for the next 24 month(s), as a result of injury or sickness, You are unable to perform with reasonable continuity the Essential Duties necessary to pursue Your Occupation in the usual and customary way. After that, as a result of injury or sickness You are unable to engage with reasonable continuity in Any Occupation.”
Your Occupation or Your Usual Occupation is defined as: “Any employment, business, trade or profession and the substantial and material acts of the occupation You were regularly performing for Your employer when the disability began. Your Occupation is not necessarily limited to the specific job You performed for Your employer.”
Essential duty is defined as: “The substantial and material acts that are normally required for the performance of Your Usual Occupation, which cannot reasonably be omitted or modified. To be at work for the number of hours in Your regularly scheduled workweek is also an Essential Duty.”
Hartford knew that Ms. Bruce could not do her own job as her employer required her to do it, but nonetheless terminated her “Your Occupation” benefits because Hartford claimed that Ms. Bruce could do her own job as other employers in the national economy required it done. Hartford’s witnesses testified that that is how they and Hartford always interprets and applies this language of its policies.
Hartford interprets and applies the policy it issued to Ms. Bruce’s employer (which appears to have the same relevant terms as policies Hartford issues to all California-based employers) as if it is the same as different policies it issues which define own occupation as “Your Occupation as it is recognized in the general workplace. Your Occupation does not mean the specific job you are performing for a specific employer or a specific location.”
It’s our opinion that Hartford cannot honestly claim terms in other policies apply to policies with different terms. In our opinion, Hartford’s interpretation of the policy applicable to Ms. Bruce was dishonest, in bad faith, and fraudulent.
If you have a disability policy with Hartford which has the same definition of “Your Occupation” as the definition applicable to Ms. Bruce and if Hartford denied or terminated your “Your Occupation” benefits because it claimed that you can perform the duties of “Your Occupation” as other employers require it to be done or as it done in the national or general economy, even though you couldn’t do your own occupation as your employer required it to be done, please contact us immediately at 855-837-5333.
Hartford Life And Accident Insurance Company Misapplied The Definition Of “Any Occupation” In Certain Of Its Disability Policies
Hartford Life and Accident Insurance Company issues many different disability policies. Some – primarily those issued to employers based in California – define “Any Occupation” as “an occupation in which you could reasonably be expected to perform satisfactorily in light of your age, education, training, experience, station in life, and physical and mental capacity.” This definition is based on the California Supreme Court’s decision in Erreca v. Western States Life Insurance Company (1942) 19 Cal. 2d 388.
The California Supreme Court explains this standard, in part, as follows: “This construction of the words any occupation is based upon the theory that it is unreasonable to deprive an uneducated laborer, disabled from performing any manual work, of the benefits of his policy, because he might, notwithstanding those disabilities, with training and study pursue a profession at some future date, or become an accountant or banker. And it would be equally unreasonable to hold that a doctor, lawyer, or business executive is not totally disabled from engaging in any occupation or from performing any work because he is able to run a news stand or work as a day laborer.”
Our client, Loretta Bruce, was a pre-school teacher for 36 years. She holds a Child Development Site Supervision Permit from the California Commission on Teacher Credentialing. Her permit was renewed periodically as required by law.
After she became disabled, Hartford Life and Accident Insurance Company ultimately paid two years of “Your Occupation” benefits but then refused to pay “Any Occupation” benefits because it reasoned that Ms. Bruce could work at an entry-level, unskilled employee at, for example, a copy service or a public office. According to Hartford, despite her age, professional education and training, and status as a permitted pre-school Child Development Site Supervisor, and 36 years’ experience as a pre-school teacher, working as an entry-level, unskilled job is consistent with Ms. Bruce’s age, education, training, experience, and station in life.In the words of the Supreme Court in Erreca, Hartford is basically claiming that Ms. Bruce is not totally disabled from engaging in any occupation, because, in effect, she is (according to Hartford) able to run a news stand or work as a day laborer. In our opinion, Hartford’s decision on that point was deliberately dishonest, in bad faith, and fraudulent, and misapplies the requirements of California law and thus of the policy.