Case Studies

Ms. C.
1111 Street Address
Anywhere, PA, 00000

Dear Ms C.:

Claim Appeal Fiduciary Services, Inc. (“CAFS”) has had the opportunity to review and consider your final Appeal for continued benefits under the X Corporation Long Term Disability Plan (the “LTD Plan”or the “Plan”).  CAFS is the designated independent fiduciary charged with the responsibility of processing your final disability claim appeal under the LTD Plan, in accordance with the terms of the LTD Plan. For the reasons stated in this letter, CAFS approves your Appeal and reverses the previous decision regarding your claim.  X has been informed of this decision and will reinstate your benefits as soon as practicable, effective for the period beginning March 1, 2006.

Specific Reasons for Determination and Reference to Plan Provisions

The Administrative Record regarding your claim indicates that you were employed by X’s Anytown facility as an Assembler. Your first day of absence was June 13, 2001.

You first applied for benefits under the Plan on or about June 20, 2001. After a periodic review of the Administrative Record, the Claims Coordinator at [Z, Inc.] the Plan’s third party administrator (“TPA”) determined that you were able to perform a sedentary occupation, and therefore, you were denied continuing benefits under the LTD Plan, as of March 1, 2006.

You were informed by letter, dated February 9, 2006, of the initial denial of your benefits claim, effective March 1, 2006 and of the Plan procedures for appeal. By letter dated March 6, 2006, you filed a first level appeal of the initial denial, and enclosed a letter from your treating physician, Dr. A., along with other medical documentation.

By letter dated April 27, 2006, TPA’s Appeal Coordinator informed you that the initial denial of benefits under the Plan was upheld. The letter also advised that a second appeal could be submitted to CAFS within 180 days of such letter’s receipt. Your appeal to CAFS, dated June 29, 2006, enclosed a letter from another treating physician, Dr. B, who confirmed Dr. A’s opinion that you are totally disabled from any occupation, including sedentary work, and have been so disabled throughout the relevant period.

Based upon information in the file, CAFS tolled the file and with the assistance of the TPA, obtained an independent medical examination, that provided additional information for the record of your appeal. In addition, you submitted the additional information stated above.

Plan Provisions that are Applicable

Pursuant to the LTD Plan, a covered disability is defined as follows:

During the first 24 months of such disability, inclusive of any period of short term disability, you are totally and continuously unable to perform the essential duties of your employment with the Company, or the duties of any other suitable alternative position with the Company; and

During the continuation of such total disability following the first 24 months, you are totally and continuously unable to engage in any occupation or perform any work for compensation or profit for which you are, or may become, reasonably well fitted by reason of education, training or experience - at the Company or elsewhere. Page 9, LTD Plan Summary Plan Description (“LTD SPD”).

The LTD Plan grants X, and its designee, complete discretionary authority regarding the interpretation of the LTD Plan as follows:

The Plan Administrator shall have discretionary authority to determine eligibility for benefits and to construe any and all terms of the Plan, including, but not limited to, any disputed or doubtful terms. The Plan Administrator shall also have the power and discretion to determine all questions of fact and law arising in connection with the administration, interpretation and application of the Plan. Any and all determinations by the Plan Administrator shall be conclusive and binding on all persons.  The Plan Administrator may delegate this authority to a person or entity and such person or entity shall have all of the discretionary authority, rights, duties and obligations of the Plan Administrator under the Plan. Page 14, LTD SPD.

Pursuant to the LTD Plan, X or its designee are the “Plan Administrator” for purposes of the plan. Page 25, LTD SPD.

Through a written agreement dated June 1, 2003, CAFS has been delegated all authority under the LTD Plan to render final determinations with respect to claim appeals and is the delegated entity for purposes of the Plan.

Reasons for Claim Approval and Application of the Plan

A review and analysis of your record reveals several instances in which either Plan terms or the results of the medical evidence demonstrated sufficient, credible information to support your continuing disability under the Plan.  As a result, the prior decision to deny your continued LTD benefits is overturned.

In February 2006, when the Claims Administrator, denied your claim, it focused its decision on the Functional Capacity Evaluation (“FCE”) conducted on March 25, 2005. A review of the FCE report revealed that the physical therapist was unable to make any conclusions as to your functional capacity because the FCE was terminated when your blood pressure rose to 168/103, your respirations to 20-24 per minute and your heart rate to 86 per minute. Therefore, the March 2005 FCE does not provide substantial evidence to support your ability to perform sedentary work under the Plan’s terms.

In April 2006, a psychiatric review of your claim file was conducted. This was arranged for by the Claims Administrator and resulted in a clear recommendation that an Independent Psychiatric Examination be undertaken. The Claims Administrator apparently misread the recommendation, and no such independent examination was undertaken. The omission of this examination initially provided support for your claim from a procedural perspective. Consequently, CAFS tolled the file and obtained this Independent Psychiatric Examination, which was entered into the record of your appeal. This examination revealed a GAF score of 60. This information was accompanied by other information regarding your capacity to perform work in an office environment that was inconclusive.

With respect to your fibromyalgia, in April 2006, the third party administrator obtained an Independent Medical Review of the record, including the information you submitted. This medical review of your file applied a definition of disability which is not the exact definition found in the LTD Plan. In addition, it did not fully consider all of the information, or the Social Security information that you had previously submitted. Therefore, the April 2006 medical review cannot be fully relied upon for a denial of your claim.

Finally, no co-morbid analysis appeared in your record that considered the cumulative impact of your medical conditions. CAFS obtained an additional independent file review from an Occupational Medicine specialist. This specialist determined that based on the entire record, considering all of your medical conditions, you were disabled under the terms of the LTD plan, as of the date of the denial. The identity of this medical specialist, and their credentials will be provided upon request.

As a result of the foregoing information and analysis, and taking into consideration the medical documentation that you provided from your treating physicians, especially the March 2006 letter from Dr. A, and his supporting treatment notes and test results, and the additional information obtained as needed by CAFS, it has been determined that as of March 1, 2006 you continued to meet the definition of disability under the LTD Plan. Therefore, based upon these facts, your final appeal for benefits under the Plan is approved, and the prior decision to deny your benefits is overturned.

You will receive a catch up payment, with applicable interest, by check, from the TPA, under separate cover, representing the total amount of benefits from March 1, 2006 through the date of this letter (“Back Benefits”). Thereafter, you will receive benefits monthly as provided for under the Plan.

Additional Information

Pursuant to the Plan terms, this final review has been a “fresh” look, without deference to any prior denial decision. In addition, the final review was conducted by CAFS, which is a person or entity, not involved in the prior denial decision, and which is not a subordinate of the prior decision maker.

You are entitled to receive, upon written request and free of charge, any documents, records and other information that you have not yet received and that were relied upon in making this benefit determination, or that were submitted, considered or generated in the course of making this benefit determination, or that demonstrate compliance with the Plan claims processing administrative procedure. Other than the documents referred to in this letter, no other internal rule, guideline, protocol or other similar criterion was relied upon in making this determination.

This is the last and final review of your claim for LTD benefits as referenced above. This decision cannot be relied upon for any claim you may have in the future relating to LTD benefits under the Plan. You will need to continue to comply with your obligations under the Plan in order to continue to receive LTD benefits, including, but not limited to, the periodic submission of updated medical documentation, and or medical examinations, to substantiate that you continue to meet the definition of covered disability under the Plan.

If you have any questions regarding the continuation of your LTD benefits, please refer to the contact information that you will receive with your Back Benefits payment.

Very Truly Yours,

Claim Appeal Fiduciary Services, Inc.

By___________________________

Patricia Fries, Senior Claims Analyst

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