After several months of back-and-forth with Equitable Life & Casualty Insurance Company, a Missouri woman has filed an insurance claim denial lawsuit in hopes of finally getting her benefits.
Plaintiff Janice C. is bringing this claim against Equitable Life claiming that she has maintained a disability life insurance policy with Equitable Life since 1998, and that she has depended on skilled nursing and assisted living service for many months, yet Equitable Life has still failed to properly pay the benefits she is due.
Janice says in her claim denial lawsuit that due to severe cognitive impairment she has lived in an assisted living residence since June 2014. In September of the same year, she was upgraded from assisted living to skilled nursing.
She filed a claim for benefits in November 2014 under her Equitable Life disability life insurance plan. In January 2015, Equitable Life denied Janice’s claim. The stated reason for the denial was that, according to her assisted living facility’s records, Janice needed help with only one activity of daily living, or ADL. Equitable Life said that to receive payments under her policy, Janice would have to need assistance with at least two activities of daily living.
Janice formally appealed the denial. She submitted additional medical evidence showing that she needed help with “nearly all ADLs” due not just to her cognitive impairment but also to Parkinson’s disease.
After reviewing the claim, Equitable Life upheld its denial. In the company’s March 2015 letter, it cited an assessment made by the assisted care facility in October 2014 that showed Janice had only one activity of daily living that qualified for assistance.
Janice alleges that even though a later assessment from January 2015 showed qualifying evaluations for at least two ADLs, the company denied that that evaluation showed any significant change in Janice’s qualifications.
The Last Word from Equitable Life
Janice claimed benefits again in July 2015, submitting with her claim assessments from March and June that both showed evidence that she says should have qualified her for benefits.
Finally, in August 2015, Equitable Life granted benefits, but only from the date of the March 2015 assessment. In explaining why benefits had not been granted from the date of the earlier January 2015 assessment, the company stated that only two of the ADLs listed in that assessment were qualifying ADLs under Janice’s policy.
However, according to Janice her disability life insurance provides for payment of benefits where two qualifying ADLs are shown. Even though the January 2015 assessment apparently showed two qualifying ADLs, she says, the company did not grant coverage from that date.
Janice reports that as of the date her life insurance attorney filed her insurance claim denial lawsuit, Equitable Life had still not paid her any benefits.
Janice now argues that Equitable Life’s multiple denials amount to a breach of their contractual agreement. She says that the company had no good cause or excuse not to pay her claim. She also notes that even though the company made a partial grant, it has not offered to pay the maximum amount at which it had valued her claim.
Janice further alleges that Equitable Life’s refusal to pay benefits after assuring her through their policy that such benefits would be paid constitutes fraud and misrepresentation. For relief, Janice seeks an award of damages plus prejudgment interest, as well as a declaration by the court clarifying the parties’ rights and obligations under the policy.
This Equitable Insurance Disability Insurance Lawsuit is filed in the U.S. District Court for the Western District of Missouri.
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