Tuesday, April 16, 2013


This seems to be a very strange case:

"Julie Heimeshoff ... worked in public relations at Wal-Mart. In August 2005, she filed a group long-term disability (LTD) insurance claim, saying that she was unable to work due to lupus and due to pain from fibromyalgia."

Now, fibromyalgia is not to be taken lightly: it's "a disorder characterized by widespread musculoskeletal pain accompanied by fatigue, sleep, memory and mood issues."

The challenge is that, unlike (say) a broken leg, there may be no obvious cause or way to verify the extent of a person's condition. So these can be tricky claims to adjudicate. In this case, Hartford Life (the LTD carrier) seems to have taken over a year to deny the claim. One presumes that there was a flurry of medical records flying back and forth between Hartford and Ms Heimeshoff's health care provider(s).

About a year after the initial denial, Ms H appealed the denial; Hartford re-confirmed it a few months later.

Fast forward to 2010 (remember, the claim was initially filed in 2005 and denied in 2006) and she sues Walmart and Hartford. Hartford argues that that she'd run out the clock because she'd failed to "[begin] any legal actions within three years after the date when she was supposed to give the company proof of her loss, rather than three after the date when the claim accrued."

That part's important, because it's where I had to call in some expert help - more on this in a moment.

In the event, Ms H countered that the statute of limitations didn't apply because they were talking about two different time periods, and Hartford's was incorrect. She lost that round in 2012 (some 7 years after the initial claim), and proceeded up the food legal chain where the 2nd U.S. Circuit Court of Appeals upheld the the lower court's decision.

But that's not the end of it: the case has been appealed to the Supreme Court, which has agreed to "take up only first question presented -- about when a statute of limitations should accrue for judicial review of an ERISA disability adverse benefit determination."

What I was having (and am still having) so much trouble with is the whole timing issue. Or, rather, issues: there's a time lapse of a year between the initial claim and the original denial, then another year before the appeal, and then three more years until she filed suit.

So I turned to a good friend who is also an experienced hand in the non-medical benefits field (and specifically, group short and long term disability cover). Over the course of several emails, he helped me come to understand the basic issue (and kudos for his patience with me!):
"Walmart has deep pockets, and as her employer prior to disability her attorney is certainly going to include them, along with the insurance company in the suit.  My guess is that they were simply hoping for some nice settlement check at that point, but alas, they'd missed the statute of limitations.   I have to feel for the lady on some level if she's hurting, but if so, why did she wait so long?

Her first filing was in 2005, so if she were ultimately going to file suit, then it would've had to be done within 3 years of when she first provided proof of loss, which would be no later than 2008"
That was the sticking point. And it helped to finally understand what SCOTUS is looking at: When does the clock actually start?

If it's the first denial (2006), then three years is up in 2009, but she waited to file her suit until 2010. That seems open-and-shut. But it's apparently not that simple (else why would they agree to take it up?). If it started with the confirmation of denial in 2007, though, she seems to have sneaked in under the wire.

I think the lesson to take from this is that if your claim is denied, and then denied again, maybe it's time to see a lawyer, and not wait until the last minute to do so.
blog comments powered by Disqus