Guardian Life is a Fortune 500 company and one of the biggest disability insurers in the U.S. Like all disability insurers, Guardian has an inherent conflict of interest that incentivizes it to reject disability claims. See Metro. Life Ins. Co. v. Glenn, 554 U.S. 105, 115 (2008). When you’re filing, appealing, or litigating a long term disability claim with Guardian, it’s important to understand how to avoid the common traps Guardian uses to deny or terminate benefits.
Riemer Hess has successfully handled many disability claims, appeals, and litigations with Guardian for our clients. We understand the tactics Guardian employs to deny paying out benefits for its claimants and have developed proven strategies to combat these methods. Below we’ll discuss the common tactics Guardian uses to deny disability claims and how Riemer Hess can help you maximize your chances to win benefits from Guardian.
What common tactics does Guardian use to deny disability claims?
Guardian utilizes various strategies to reject disability claims. In our experience, these strategies may include:
- Ignoring approval of Social Security Disability benefits: Generally speaking, the Social Security Administration (SSA) has a higher standard to meet for disability than most Guardian LTD policies. The SSA operates independently of Guardian and makes its own determination using a different, often stricter definition of disability. That means should you be approved for Social Security Disability benefits, this approval can be used as further evidence of your disability. Guardian may ignore or overlook that the SSA deemed you disabled and choose to deny your claim regardless.
- Relying on their in-house paper reviewers and “independent” medical examiners: Guardian may have their in-house medical and vocational consultants review your paper file, including your submitted medical records, to give their opinion on whether or not you are disabled. Guardian may also choose to send you for a so-called “independent” medical examination with one of their doctors. Of course, these consultants and examiners are not independent because they are paid by Guardian, either directly or through a third party. The reports are often tainted with bias. Guardian can then use these biased reports as a basis to deny your claim.
- Arguing that your disability is not severe enough to prevent you from working: Guardian may claim that your medical evidence does not demonstrate your symptoms as severe or frequent enough to inhibit your ability to work. Similarly, Guardian may misconstrue the nature of your occupation to deny your claim. By ignoring the breadth of your job duties, Guardian may falsely claim you are able to work.
- Understating or mischaracterizing the level of medical treatment that you have received: Guardian may posit that you are not complying with recommended treatment from your providers in violation of your policy. This may be a mischaracterization of your treatment plan. For instance, many providers will recommend more conservative treatment options before resorting to riskier treatments such as surgery. However, Guardian may claim that by not undergoing more extreme treatment, you are not in compliance with your policy and therefore deny your benefits.
- Calling your doctors to catch them off guard and get incomplete information from them: Guardian may have their medical consultants contact your doctors to discuss your claim. Oftentimes this contact is made by phone. There is no record of these calls beyond the consultant's own notes. It may also catch your doctor off-guard, who is not prepared offhand to explain your condition and restrictions and limitations. This can result in an incomplete and/or inaccurate picture of your provider's opinion on your ability to work. Regardless, Guardian may use this conversation to deny your benefits.
What should I do if Guardian denies my disability claim?
While devastating, the good news is that a claim denial from Guardian isn’t the end of the road. ERISA grants you the right to an administrative appeal. This appeals process is conducted internally through Guardian, with a new representative reviewing your claim and allowing you the opportunity to submit additional evidence of your disability.
If Guardian denies your disability claim, here are some first steps you can take:
- Review your denial letter. If Guardian rejects your claim, they are required to provide this denial in writing. Your denial letter will contain crucial information including Guardian’s reasoning for their denial and your appeal rights. Understanding why they denied your claim will help you know what new evidence to obtain and submit with your appeal. The appeal rights will explain how to file your appeal and provide the deadline to file. If you miss this deadline, you may have little recourse. ERISA provides that you must exhaust your remedies before you can sue, which includes the administrative appeal process.
- Request your claim file from Guardian. ERISA gives you the right to obtain your claim file from Guardian. The claim file contains all documentation Guardian used to make their determination, including all submitted medical records, vocational evidence, as well as Guardian’s internal notes and any reports form their consultants or examiners. The claim file can be key to seeing why Guardian really denied your claim.
- Obtain additional evidence. If you simply write a letter telling Guardian their denial was unfair and neglect to submit any new evidence, Guardian is likely to uphold their initial decision. Your appeal should include new information that supports your medical disability and inability to work. This may include updated medical records, a letter of support from your treating provider(s), additional testing, and affidavits from co-workers, family members, and yourself that explain how your condition has impeded your functioning in daily activities, including work.
- Speak to an attorney. We always recommend speaking with a disability attorney before filing or appealing a long term disability claim. The ERISA attorneys at Riemer Hess will be able to review your correspondence from Guardian, LTD policy, and any relevant documentation to provide you with a personalized strategy for successfully filing, appealing, or litigating your Guardian long term disability claim.
Have courts criticized Guardian's disability claim handling practices?
Yes. Courts have criticized Guardian for their disability claims handling practices in denying disability benefits. For example:
- In Johnson v. Guardian Life Ins. Co. of Am., 2017 WL 4870909, at *10 (D. Conn. Oct. 27, 2017), the Court criticized Guardian for ignoring the plaintiff's favorable Social Security Disability determination.
- In Tarasovsky v. Stratify, Inc. Group Short Term Disability Plan and Long Term Disability Plan, and the Guardian Life Insur. Co. of America, 2013 WL 2156262, (N.D. Cal. May 17, 2013), the Court criticized Guardian's reliance on the "dubious and arbitrary conclusions" of its doctor, which was contrary to the opinion of seven other physicians.
- In Streit v. Guardian Life Ins. Co. of America, 374 F.Supp.2d 1109, 1115 (M.D.Fla., 2005), the Court criticized Guardian for ignoring considerable and internally consistent evidence provided by the plaintiff.
- In Johnson v. Guardian Life Insurance Company of America, 2017 WL 4870909, (D.Conn., Oct. 27, 2017), the Court criticized Guardian for: (1) relying on the opinions of its medical reviewers when those opinions were contradicted by the medical documentation that they reviewed; (2) for failing to provide a "full and fair review"; (3) for ignoring medical documentation that demonstrated fluctuation in plaintiff's medical condition; (4) for terminating previously approved benefits "in the absence of a change in condition"; and (5) disregarding the plaintiff's favorable Social Security Disability determination.
What strategies work best against Guardian?
Riemer Hess is highly familiar with Guardian’s tactics and knows how to proactively avoid falling into their common traps. Some of these strategies include:
- Understand your policy: Riemer Hess will thoroughly review your Guardian policy and its terms, including the definition of disability, waiting period, and benefit amounts.
- Gather thorough medical documentation: Riemer Hess will help you obtain comprehensive medical documentation that supports your claim from all healthcare providers involved in your care. If necessary, Riemer Hess will recommend and refer you for additional testing, such as a neuropsychological evaluation or Functional Capacity Evaluation, that bolsters your claim and addresses all of your symptoms and their severity.
- Prove you cannot work. Your benefits are dependent on proving your medical condition prevents you from performing the material duties of your occupation. To circumvent any unfamiliarity on Guardian’s end, Riemer Hess will collect the proper vocational evidence that lays out all of your material job duties, both physical and cognitive. This may include enlisting a vocational expert to prepare a vocational assessment on your behalf. Riemer Hess ensures that Guardian cannot plead ignorance to the full scope of your occupational responsibilities and functions.
At the same time, there is no “one size fits all” strategy when dealing with Guardian. Riemer Hess recognizes that your situation is unique and tailors our approach to the specific circumstances of your claim. We utilize our experience with Guardian in conjunction with the special facts of your claim to formulate a customized strategy designed to win benefits.
How can Riemer Hess help with my Guardian long term disability claim?
Riemer Hess understands how much is at stake when you need long term disability benefits. We also know that Guardian won’t make it easy for you to collect the benefits owed to you. We’ve helped hundreds of clients obtain and protect their Guardian long term disability insurance benefits.
Take for example our client Joel. Joel was a young, very successful sales executive building his career when he was struck with chronic headaches. The headaches were so intense and frequent that Joel could barely function, never mind work. A doctor eventually diagnosed him with vestibular migraines. Despite all of his efforts to treat his symptoms, they progressed to the point Joel could no longer work. He had no choice but to leave work and file for short term disability benefits with Guardian, knowing he would need benefits on a long-term basis.
To Joel’s dismay, Guardian denied his short term disability claim after a quick review. Guardian’s denial letter gave little insight into why they denied Joel’s claim. After an informative consultation with Riemer Hess, Joel retained our attorneys to handle his appeal.
Riemer Hess immediately sprang into action. We requested the claim file, which showed that many medical records were missing and Guardian had little understanding of Joel’s occupation. To remedy that, Riemer Hess requested the pivotal vestibular testing Joel had undergone from his treating doctor, recommended Joel to get updated vestibular testing to present newer information on his condition, and had Joel keep a symptom diary outlining all of his symptoms over the course of a month. Joel’s doctor, while supportive, was difficult to reach, so Riemer Hess stepped in to coordinate with his office. We obtained the missing medical records and a supplemental statement from the doctor in support of Joel’s disability claim.
Riemer Hess made sure to obtain all possible evidence, both medical and vocational, demonstrating Joel’s diagnosis, failed treatment efforts, symptoms, and occupational duties he could no longer perform. These were submitted to Guardian along with a comprehensive appeal letter refuting their vague reasons for initially denying the short term disability claim.
In the end, Guardian reversed their denial and approved Joel for benefits. Once the short term disability benefits were exhausted, Riemer Hess helped Joel transition to long term disability, which Guardian granted without issue. Joel was very pleased with the results and retained Riemer Hess to continue monitoring his Guardian benefits going forward.
How can an attorney help win my Guardian disability claim?
With so much at stake, it’s important to handle your Guardian disability claim correctly from the start. The experienced long term disability attorneys at Riemer Hess will help you avoid Guardian’s common pitfalls and maximize your chances of success.
The attorneys at Riemer Hess have the experience it takes to beat Guardian. If you are filing, appealing, or litigating a long term disability claim through Guardian, call Riemer Hess today at 212-297-0700 or select the button below to schedule a consultation.