When a court of law weighs in on a denied disability benefit, it can go either way. This was especially true with a recent Unum disability claim denial in which a woman suddenly lost her benefits after receiving them for nine years. Fortunately, the judge ruled in favor of the disabled beneficiary in this case – but the scales could easily have tipped in favor of the insurance company.
Disability insurance attorney Greg Dell discusses the case with fellow lawyer Victor Peña, both of whom are specialists in helping clients who struggle with a denied disability claim. They have handled well over 1,000 cases involving Unum, the world’s largest disability insurance company. This particular case was decided in the United States Court of Appeals for the First Circuit, which covers cases out of Massachusetts.
Effects of the Independent Medical Review
The disabled female claimant suffers from fibromyalgia and depression and had been on claim for nine years. She had symptoms from both conditions, which limited her capacity to work, so Unum had been paying the claim on an ongoing basis. But, at some point, Unum ordered an independent medical evaluation (IME) in which a physician evaluated her present condition.
According to attorney Victor Peña, the IME doctor concluded that the diagnoses were supported but, absent findings of abnormalities in the medical records of this condition, she was capable of performing sedentary work. The length of the exam came into question, with the disabled policyholder claiming it lasted mere minutes – but Unum still moved forward with severing her benefits after nine years of receiving them.
Victor Peña explains that Unum is one of those insurance companies in which it’s common to see a person on claim for a long period of time before they seek to terminate the coverage.
“…Somehow they find a reason, after paying this claimant for so many years for this condition – and then, absent any evidence that there’s been any improvement in the condition – Unum still finds a way to cut them off,” he says. “So that’s what happened here.”
The claimant went through an appeal, but was unsuccessful, leading to the eventual lawsuit and court reversal in her favor. So, what about this particular case made it significant enough to end with a reversal of the UNUM denial and a victory for the claimant?
Factors in a Successful Unum Disability Claim Reversal
Every Unum denied disability case is different, but in this instance, the disabled claimant happened to have two disability policies at play, both administered by Unum. There was a group ERISA policy, which is essentially a government-sponsored disability policy through Unum. And she also had an individual policy through Provident Life, which is a subsidiary of Unum. She benefited from several aspects of the policies as well as from the nature of her disabilities and her treatment history.
Because of the individual policy, her disability insurance attorney was able to introduce some additional evidence into the court proceedings. Since both policies were handled by the same insurance company, there were depositions and interrogatories that went around, ultimately aiding in the ERISA case as well.
Another crucial component in the successful outcome was that the court was able to employ a “de novo judicial review” standard when considering the case. Therefore, unlike many cases in which the insurance company gets the benefit of the doubt, including an “arbitrary and capricious” standard of review, they did not have that benefit in this one.
The court touched on two major issues in this case, according to attorney Victor Peña.
First of all, the conditions of the policyholder, fibromyalgia and depression, are based primarily on subjective complaints. The court stated that it’s unreasonable for an insurance company to require objective proof of a condition that’s subjective in nature. So, while the claimant is still required to provide objective proof that they’ve got physical limitations resulting from the symptoms of the condition, the insurance company can’t require objective proof of the actual condition itself.
Another huge thing, according to Victor Peña, was the patient’s medical history. The court found that her extensive medical records, ongoing level of treatment, and heavy medications showed credibility and made it unreasonable to assume that she was just trying to get disability benefits.
Finally, the court addressed a secondary issue: what’s known in the insurance worlds as “limitations in policies.” Because the claimant’s policy had a 24-month limitation of payable benefits for the condition of depression, the coverage for that specific condition would end after two years. However, the court stated that, in order to limit benefits, Unum would have the burden to show that this limitation would apply – and that the company hadn’t met their burden.
Regardless of what kind of Unum disability claim you have, there are many intricate layers that come after the denied claim, appeals and eventual lawsuit. The seasoned and expert long-term disability insurance attorneys at Dell & Schaefer can deal with the strong-arm techniques of insurance companies and put you in a position to receive a well-deserved disability insurance benefit after an Unum denied claim. They represent clients in every state, and the initial consultation is immediate and free. Just click the free consultation button on the company website, or call for a direct conversation.