Psychiatrist Suffering From Back Injury Sues Provident Life And Unum For Denial Of Disability Benefits

Recently, a federal lawsuit was filed by a California disability lawyer against the Provident Life and Accident Insurance, Co. (Provident) and Unum Group (Unum). The Plaintiff, James M., M.D., worked as a Psychiatrist. Plaintiff applied for a disability insurance policy from Provident in or around December 1982.

Like many claimants, Dr. James M. was forced to file a lawsuit against Provident Life and Unum after being denied continued long term disability benefits.

Facts Of The Case Against Provident And Unum

Plaintiff worked as a Psychiatrist until February 28, 1997 when the increasing back pain and diminished ability to work stemming from suffering a back injury carrying a heavy UPS box on October 16, 1995 caused him to stop working. Plaintiff was unable to work due to being unable to concentrate and think clearly.

Plaintiff filed a disability claim in March 1997. He notified Provident and Unum that his claim was based upon an injury that occurred in 1995 and not sickness.

In 1996, Provident Companies, Inc. had entered into General Service Agreements with each of its subsidiary insurers due to the acquisition of the Paul Revere Life Insurance Company by Provident, which is now the Unum Group.

Between March 1997 and June 1997, two adjusters and one field investigator determined that Plaintiff did not have any significant back problems before the 1995 injury, leading to the approval of disability payments on a conditional basis based upon further review on June 27, 1997.

In a letter dated January 21, 1999, Provident asked GENEX Services Inc. to have Plaintiff examined by Independent Medical Examiner Dr. Gerald C., M.D. At that time, GENEX was a wholly owned subsidiary of Provident.

On February 18, 1999, Dr. C. examined Plaintiff and prepared a report for Provident.

During the Spring and Summer of 1999, Provident continued to seek additional information on Plaintiff’s medical condition, gaining opinions of Dr. Peter B. and Dr. Walter S. They confirmed the earlier findings that Plaintiff was limited by the documented physical conditions and associated impairments. This led to Provident ending their investigation of the claim and approving Plaintiff’s benefits.

On August 20, 1999, Ms. W., Customer Care Coordinator for Unum/Provident wrote to Plaintiff and advised him that the Plaintiff would only need to update Unum/Provident on Plaintiff’s continuing disability on a semi-annual basis and the Plaintiff’s doctor on an annual basis for the Plaintiff to continue receiving monthly disability benefits.

Unum Terminates Plaintiff’s Long-Term Disability Benefits

Via a phone call, Unum Group adjuster Ms. T. told Plaintiff that Unum would terminate long-term disability benefits after Plaintiff turned 65 on August 22, 2010 due to his disability being caused by a sickness and not by an accident.

Plaintiff responded by saying that he thought the benefits would be paid for a lifetime due to the fact that the disability was caused by an accident and not by a sickness, as had seemed to have been proven back in 1999.

On May 18, 2010, Ms. E., another Unum Group adjuster, took over Plaintiff’s claim and reviewed it for Accident/Sickness.

Between May and June 2010, several phone calls took place between Plaintiff and Ms. E. regarding the status of Plaintiff’s claim and the anxiety caused by Unum’s handling of Plaintiff’s disability claim. Plaintiff had also sent additional medical records dating from 1999 to show that the disabling injury was due to injury, not sickness.

On July 29, 2010, Ms. E. informed Plaintiff via letter that the investigation would continue, but that the benefits would continue to be paid each month in the amount of $3,880 beyond August 22, 2010.

Throughout October to December 2010, Plaintiff was updated that the benefits would continue to be paid while the investigation was ongoing.

On December 27, 2010, in response to Plaintiff’s phone call and voicemail to Ms. E., Ms. E. told Plaintiff that his injury was degenerative in nature, meaning that it was not due to an injury and that it would fall under the sickness provision of his policy. This led to the decision by Unum to terminate Plaintiff’s benefits after the age of 65.

Plaintiff has exhausted all administrative remedies, leading to the filing of this lawsuit.

Unum Lawsuit Filed By California Disability Lawyer

The terms of the lawsuit state that Unum committed the following to the plaintiff:

  • The failure to continue paying long-term disability benefits that were owed to the Plaintiff as defined under the Policy
  • Affirming or denying coverage under the Policy within a reasonable amount of time
  • Not informing Plaintiff that his accident-based claim was being administered under the sickness provision of his Policy
  • Blameworthy or inequitable conduct
  • Unum’s conduct led to Plaintiff not protecting his rights in 1997-1999, leading to his disadvantage now in regards to his disability claim, since the medical records from 1997-1999 are no longer available due to Unum’s failure to inform Plaintiff that his disability claim was being administered under the sickness provision of his Policy
  • Unum’s conduct led to a disadvantage of the Plaintiff that they are now taking advantage of
  • Caused undue stress and financial damage to the Plaintiff due to the unexpected termination of Plaintiff’s benefits after age 65

The Following Relief Is Sought By The Plaintiff From The Unum Lawsuit

Due to Unum’s actions, Plaintiff requests the Court to grant the following relief:

  • All past due contract benefits along with accrued interest
  • All future benefits under the contract due to Unum’s bad faith
  • Award of damages for the mental and emotional distress caused by Unum’s bad faith
  • All attorney fees and court costs
  • Exemplary damages that are proved in court and that take into account Unum’s attempts at financial gain at the expense of the Plaintiff
  • All pre-judgment and post-judgment interest
  • All other relief that the Court deems proper and just