Unum denies disability insurance benefits and refuses to consider findings of total disability by the Social Security administration and a workers compensation doctor. Let’s take a closer look at these recent lawsuit filed by a California disability lawyer.
The UNUM Disability Claim Denial
In the case of Jose Ramirez v Unum Life Insurance Company (UNUM), Mr. Ramirez was working as a Direct Sales Representative for Time Warner Cable Inc. The list of his duties included going door to door making sales for cable, television and internet services and performing all the necessary installations once a sale was concluded. All this had to be done to fulfill a quota based on a two weeks sales cycle. While employed with Time Warner Cable Inc., Mr. Ramirez participated in a group benefit plan which was underwritten by UNUM and sponsored by Time Warner Cable Inc.
On March 2008, Mr. Ramirez began to suffer pain in his lower back which worsened and immobilized him over a period of time hence preventing him from performing the material duties of his occupation. This ultimately resulted in him having to stop work on July 28th 2008. Consequently, Mr. Ramirez applied for disability benefits to UNUM.
Based on the terms of the disability plan, Mr. Ramirez was entitled to receive monthly long term disability benefits equal to 60% of his monthly earnings until the age of 65 with his continued disability. Under the plan being disabled means if “You are limited from performing each of the material duties of your regular occupation due to your sickness or injury and you have a 20% loss or more in your indexed income monthly income due to the same injury or sickness.”
Upon meeting the criteria of being disabled under the plan, the insured, after a 26 weeks elimination period, would be eligible to receive disability benefits as long as he continued to be disabled. After 24 months from the time the insured first received his disability benefits, the insured, to continue receiving disability benefits, must be “unable to perform the duties of any gainful occupation” for which he is “reasonably fitted by education, training or experience” due to the same sickness or injury.
Mr. Ramirez had duly paid all the premiums for his long term disability benefits that were due under the group benefit plan and had fulfilled all the obligations required under the plan for his claim of disability benefits to be processed by UNUM. This also included submitting a timely application for the benefits and presentation of medical evidence that established Mr. Ramirez’s disability status. According to Mr. Ramirez’s attending physicians, he was suffering from chronic and debilitating back pain as well as extreme pain which prevented him from carrying out all the material duties of his occupation as a Direct Sales Representative for Time Warner Cable Inc.
UNUM on April 3rd 2009 denied Mr. Ramirez’s claim for long term disability benefits based on the strength of UNUM’s own physicians’ determination that despite Mr. Ramirez suffering from spondylosis, degenerative disc changes and spinal stenosis, the medical information did not support any limitations or restrictions that would had prevented Mr. Ramirez from performing the duties of his job during the elimination period.
Appeal to UNUM’s Decision
Mr. Ramirez then on October 7th 2009 appealed UNUM’s decision to deny his claim for long term disability benefits and submitted additional supporting medical evidences that stated Mr. Ramirez was suffering from a disc herniation and was unable to sit or stand for any prolonged period of time. The medical evaluation also stated that Mr. Ramirez, apart from experiencing decreased sensation, was suffering from a pain in his lower back which goes down into his legs. In addition, MR. Ramirez also experienced “numbness and tingling in his left leg”.
On December 31st 2009, UNUM again arbitrarily and unreasonably denied Mr. Ramirez’s claim for disability benefits without considering several material duties of Mr. Ramirez job’s scope which included having to perform cable installations. As such, Mr. Ramirez through his California disability attorney asserted that he was entitled to an additional appeal because of UNUM’s violation of the provisions under ERISA that prevented Mr. Ramirez from receiving a full and fair review of his claim. In response, UNUM refused to entertain any further appeal from Mr. Ramirez.
Despite UNUM refusal to entertain any further appeal from Mr. Ramirez, he still submitted additional supporting documentations from his Worker’s compensation case that he was “not orthopedically capable of performing his usual and customary job activities”. UNUM replied to Mr. Ramirez on December 30th 2010 that it was refusing to consider or review any of this new information even though there was nothing to prevent them from doing so and was adamant in denying Mr. Ramirez claim for long term disability benefits. On March 4th 2011, Mr. Ramirez submitted correspondence from the Social Security Administration (SSA) that determined he was declared disabled as of July 28th 2008 and was entitled to Social Security benefits beginning from January 2009. The SSA concluded that there was no occupation in the national economy that Mr. Ramirez could perform with the state that he is in. UNUM replied and again stated that they refused to consider or review any of this new information and further inform Mr. Ramirez that his administrative records were closed as of December 31st 2009.
The Claim for Short Term Disability Benefits
Mr. Ramirez was also covered under a self insured short term disability policy issued by UNUM. Under the policy, the insured was supposed to receive benefits if the insured was to become totally disabled. Mr. Ramirez was determined to be totally disabled by UNUM and was receiving short term disability benefits. On January 29th 2009, UNUM informed MR. Ramirez that it was terminating his benefits beyond November 17th 2008.
On the second review, UNUM informed Mr. Ramirez that his claim would be paid until December 5th 2008 on the grounds that despite medical evidence showing Mr. Ramirez was suffering from Spondylosis, Spinal Stenosis, chronic leg pain, they did not support any limitations and restrictions to Mr. Ramirez beyond December 5th 2010. As mentioned above in his appeal to the denial of his claim for long term disability benefits, Mr. Ramirez on October 7th 2009 also appealed to UNUM regarding this decision by UNUM to deny him his short term disability benefits but was also unsuccessful. Further documentation was submitted in December 2010 and on March 4th 2011 but UNUM refused to review and consider any of this information.
Claim for Relief
As a result of exhausting all his administrative remedies, Mr. Ramirez has no choice but to seek relief through the court by filing this lawsuit against UNUM. The relief sought by the plaintiff in this lawsuit includes:
- The long term disability benefits payable under the plan including interest.
- The short term disability benefits payable under the plan including interest.
- A declaration that because the plaintiff was and is and continues to be disabled under the terms of the plan, the plaintiff is entitled to continue receiving both long term and short term disability benefits under the plan.
- A declaration clarifying the rights of the plaintiff.
- A declaration as to the non-compliance by UNUM with the minimum standard laid by ERRISA.
- The award of reasonable attorney fees and costs.
- Any other relief deemed appropriate by the Court.
The Employee Retirement Income Security Act of 1974 (ERISA) is regarded as one of the most comprehensive pieces of legislation that sets the minimum standard for health benefit plans that are offered by the disability insurance companies. Its primary objective is to limit any abuse and discrimination of these plans by the insurance companies. Thus if you find yourself wrongfully denied of your disability benefits by your disability insurance company, you can file an action through your disability attorney to seek to recover your disability benefits.