Kevin M. Zietz and co-counsel Todd Krauss represented Jeffrey Kopicko on a claim for long-term disability benefits denied by Anthem Life Insurance Company (Anthem). The case involved the denial of Long-Term Disability (LTD) benefits under a group plan insured by Anthem Life Insurance Company (Anthem). Mr. Kopicko was initially denied LTD benefits on the basis that his claim was excluded by a pre-existing condition provision in the insurance policy. Kevin M. Zietz and Todd Krauss were successful in getting Anthem to reverse the denial of benefits based upon application of the pre-existing condition exclusion in the policy. Anthem approved LTD benefits for a closed period of time between November 9, 2017 and May 7, 2018. Anthem went on to deny benefits beyond May 7, 2018 based upon a medical record review completed by a psychiatrist who opined that the medical evidence only supported disability for the aforementioned period of time based upon the diagnoses of major depressive disorder, generalized anxiety disorder, and agoraphobia. The nature of agoraphobia is that it causes people to self-isolate to the point where it can even be difficult to go out of the house to seek medical attention. Plaintiff in-fact self-isolated and did not seek any medical attention for almost nine months. This left a massive gap in his psychiatric medical treatment in 2018, and created a factual scenario that was in stark contrast to the LTD policy’s requirement that he be under the continuous care of a doctor for his disabling medical condition(s). When Mr. Kopicko resurfaced, he sought to establish continuity of care with new mental health professionals so that he could resume his course of treatment and have the disability paperwork filled out as required by the LTD policy. During the administrative appeal process, Anthem hired a second psychiatrist to review Mr. Kopicko’s medical records.The second peer reviewer also opined that the medical records did not meet the diagnostic criteria set for by the DSM-5 for the psychiatric conditions that Mr. Kopicko alleged were causing him to be impaired to the point that he was unable to work. The district court Judge’s ruling is important because (1) It shows that people who are disabled due to agoraphobia (and therefore not always able to seek continuous psychiatric medical treatment for perhaps as long as six months or longer) should not be penalized by having their disability benefits denied because the very essence of their medical condition makes it difficult for them leave their residence to seek medical treatment; (2) reported district court cases show that insurance companies have routinely attempted to deny disability benefits based upon psychological conditions, claiming there to be a lack of “objective” medical evidence to support disability. After reviewing the totality of circumstances in Mr. Kopicko’s case, the district court judge was not persuaded by Anthem’s peer reviewer who opined that lack of “objective psychological testing” suggested that he was not disabled beyond May 8, 2018. The judge’s decision is consistent with other rulings in the Ninth Circuit that have noted that psychiatric impairments are not as amenable to substantiation by objective laboratory testing as are physical impairments. Therefore, even though mental disorders cannot always be ascertained and verified like physical ailments, that does not mean that people with psychiatric conditions cannot successfully support their disability.

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