Long Term Disability Law BlogAttorneys Helping Disabled Claimants Nationwide

Unum Appeals: Do’s and Don’ts

Disability Insurance Attorneys Dell & Schaefer has handled thousands of Appeals against UNUM. Learn what the most important thing a UNUM policy holder needs to know before filing an appeal.

GREGORY DELL: Hi, I’m attorney Greg Dell here with attorney Stephen Jessup. And we want to talk about Unum appeals, some of the dos and don’ts, and some things that people who are in a situation where they need to file an appeal, kind of what they can expect and some of the things that we think are most important when filing an appeal against Unum. Now, we’ve handled collectively thousands of appeals against Unum. They are the world’s largest disability insurer for long- term disability. And I want to start off first with, what’s the most important thing that a person needs to file an appeal should be concerned about?

STEPHEN JESSUP: First and foremost, it’s always going to go back to the medical information. What’s in your records? There’s been a recurring theme of this idea that a diagnosis alone isn’t going to establish a disability. So just because you have a medical condition doesn’t mean that the insurance company is going to find that you’re disabled, or just because your doctor writes a note that says you need to be out of work doesn’t mean that they’re going to find you disabled. So it’s really about what’s the meat and potatoes of the medical records, the information that’s in their exams, findings, clinical findings, objective medical evidence, MRIs, x-rays, whatever the case may be based upon the medical condition.

GREGORY DELL: So what we like to do, because a lot of people call and they feel like the insurance company leads them on to believe, well, just go ahead and say you want to appeal and send in a simple letter from your doctor or send us another attending physician statement. Well, they already had that. And they denied your claim. So obviously that’s not enough. So talk for a minute about what’s different that we do with our attending physician statements and how do we work with doctors to get the appropriate medical support.

STEPHEN JESSUP: I think that one of the biggest things is when doctors are doing their records, they’re not writing records knowing an insurance company’s going to be evaluating them for disability. They’re doing it for their record keeping so they know what’s going on, have a history, can take a look at things. A lot of times, what the insurance company will do is they’ll look in there. If there’s an absence of information, they’ll assume, well, there’s nothing about it, so it’s not a problem, or sometimes the doctor will be talking about a person looks good, well nourished, weight’s good. Things have to do more with your activities of daily living and how you’re doing there as opposed to work restrictions. What would prevent you from working?

So when we’re doing attending physician statements, the biggest thing about a definition of disability is your medical condition prevents you from performing the duties of either your occupation or another occupation. So when we do the attending physician statement, we are targeting, how do we make those medical records? How do we draw the connection to occupational duties and where are those restrictions will lie? Because that’s really where you have to draw the nexus to be able to prove to an insurance company that you’re entitled to the benefit.

GREGORY DELL: So when we’re working with the physicians, what we often do is we don’t rely on that one or two-page form that Unum does. But we customize our own attending physician statement specific to the definition of disability. Like you said, if it’s an own occupation and it’s a person who has a desk job, which is very similar to sedentary, then we will specifically ask the doctor questions about can a person use the keyboard for more than four hours a day?

Can they sit in front of the computer in a fixed position for more than four or five hours a day? Can they rotate their neck 5,000 times a day? Will they have difficulty focusing? Do they need to take more than two breaks a day for more than 15 minutes? All kinds of things that the doctor will put on, because we know from having done so many claims and deposing all of these claim reps and reading the training manuals at Unum, they are looking for specific things that you have to be unable to do.

And when the claim reps are trained for hours and hours and months and months before they go to look at a claim, they basically get presented with the criteria for all different medical conditions and say, do you see A, B, C, D, and E in the claim file – sorry – in the support from the doctor? And if you don’t see that, then this person doesn’t have the appropriate restrictions and limitations. Now, that’s step one, which is great.

Unfortunately, we know that no matter how great what we send in, Unum is going to send everything out to their hired gun doctor or their internal doctor. And how often do you see that Unum is going to disagree with their internal doctor or doctor that they hire versus the information that is presented by the claimant?

STEPHEN JESSUP: Well, I mean, I think the cards are stacked against someone, especially if the information isn’t presented in a very informative way and as complete as possible. And sometimes it does come down to there are certain, like you said, vital pieces missing to the medical records or the information that when they get that, they’ll take a look at and take an honest look. And a lot of times what will happen is they may initially have an internal doctor look at it. And then if there’s a disagreement between what their doctor says and the treating physician says, then they’ll send it out for an independent review by a peer review doctor.

It makes it seem as if they’re giving you every opportunity. But we both know that what they’re doing is basically covering themselves, especially if your policy is going to fall under this idea of an arbitrary and capricious review down the road. So it’s really – the cards are stacked up against her. So it’s difficult. I mean, it’s very difficult.

GREGORY DELL: So in light of this difficulty which you’ve obviously identified, I don’t want to say that we’re doctors. But we’ve done so many claims where we’ve become quasi doctors and had so much education from our clients’ own doctors and other experts that we’ve hired that, when we draft these attending physician statements, we’re trying to draft it in such a manner where not just the insurance company, but when another doctor looks at the attending physician statement and the support from the doctor, that no reasonable doctor could find a reason to disagree with the finding of the claimant’s own doctor.

And that’s a real important art and skill that I think has really been one of the big keys to our success, that we’re able to present the information in such a way where we kind of bootstrap the outside doctor, because we know it’s going there. And even if we don’t get past that doctor, it presents very strong evidence for a lawsuit, which would be the next stage if the appeal was denied.

So every medical condition is different. We’ve seen all of them. And obviously give us a call. We’re prepared to discuss your condition and how we can help you. The other topic I want to talk about is how important is vocational assessment? And what does that mean when filing an appeal?

STEPHEN JESSUP: Well, the vocational assessment is going to be what your job is or in the idea of any occupation review, other jobs that are going to be available. A lot of people – and it’s true, they make arguments. They’d even take into consideration what my job requires me to do. But just about, I would say, every employer-provided policy defines it as how it’s performed in the national economy. So you’re not only looking how it’s performed at that employer, but you really have to take out of the global perspective of how it’s done in the national economy.

So it’s a matter of presenting that occupational information, whether you get your own experts involved or just over the – there’s a plethora of information from the Department of Labor and other standardized occupational products that allow you to look into what those duties are going to be. And a lot of times, the insurance companies try to strip it all down to no matter what you do, if it’s a desk job that’s sedentary, can you do sedentary? And they really aren’t looking at even the national economy standards of what are defined as the material duties of a job.

GREGORY DELL: The other advantage is that often we hire a vocational expert. It costs several thousand dollars to generate these reports. And many claimants don’t want to risk the money during an appeal. The fact that we handle all of our appeals on a contingency fee basis means that claimants don’t have to come up with any out-of-pocket money to pay for these reports. And only if we win is it a cost that they would be responsible for ultimately. So that’s also a big advantage for a claimant that they can get that.

A claimant would never know about hiring a vocational expert if they’ve never been in an appeal before, yet Unum almost always – they have on staff their own vocational experts. So you take the vocational report that you get. You often get all the medical records given to the vocational expert once you have all the restrictions and limitations from the doctor and then ultimately let the vocational expert make an opinion that there is either no job in your own occupation or there isn’t any occupation that you could do.

So there’s so much more to these appeals. But in this brief video, we’ve touched on the importance of medical on vocation. We encourage you to contact us if your claim has been denied by Unum. We’re able to help you anywhere in the country. We always offer a free initial consultation. And we look forward to the opportunity to speak with you.

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