As the world’s largest disability insurance company, Unum doles out its fair share of disability claim denials each and every year. That’s why a disability insurance law firm such as Dell & Schaefer has handled more than 1,000 Unum denied claim appeals. Though some policyholders attempt to fight a denied disability claim on their own, it can be an incredibly complex process with irreversible implications, especially if it eventually ends up in an ERISA lawsuit.
Disability insurance lawyer Greg Dell and fellow attorney Cesar Gavidia provide some tips and insights for disabled claimants and discuss the importance of having a very strong initial appeal of your Unum disability claim denial.
Leaving No Stone Unturned
A detailed and exhaustive approach to filing a Unum appeal is crucial, according to disability attorney Cesar Gavidia. As he puts it: Leave no stone unturned. Explaining what one of his typical appeals looks like, Gavidia describes it as being like a legal brief that he’s submitting to an appellate court. It contains exhibits and formatted sections that meticulously lay out the reasons for the appeal and the conditions that justify the policyholder receiving his or her disability insurance benefit per the written policy.
Why does he do such an intense appeal? Because it can be the claimant’s “one bite of the apple” in proving the disability. If the appeal doesn’t contain everything necessary to win an eventual ERISA lawsuit, there is no going back and changing the content in the appeal. In addition, and this is crucial to realize, no new information can be introduced after an appeal is denied by Unum (which very often happens.) Policyholders doing appeals on their own, without a competent and skilled disability lawyer, rarely know the details and proactive steps that ensure an eventual victory.
In addition, says Greg Dell, once the insurance company makes a decision to deny an appeal, nothing that happens afterwards is admissible in court.
“If something horrible happens the next day, and you become paralyzed or something that would (ordinarily) be a no-brainer whatsoever… you’d be disabled, but the court will never be able to consider that, and Unum never needs to consider that. It’s just not admissible. It’s done.”
From Claim to Denial and Appeal
After handling appeals for every type of medical condition, most of them with Unum, the attorneys at Dell & Schaefer know the process from beginning to end – and all things in-between. The first thing that happens is that a policyholder makes a claim on his Unum disability policy and receives a denial letter.
That’s the starting point for a trained attorney who’s handling the case on behalf of the insured and disabled claimant. The attorney will request a claim file, which ERISA laws dictate must be handed over in a timely manner. That file must contain every single thing that the insurance company has seen and used to deny the claim.
Cesar Gavidia notes that Unum, because of some very bad press and a bad prior reputation, now has multiple hands and sets of eyes on a disability claim. So the disability attorney will obtain every note, record, piece of information and email that’s gone between them and their qualitative reviewers.
Greg Dell adds that his law firm goes above and beyond a simple request for the file; they ask for loads of other information such as the resumes of their doctors, how much they were paid for the reviews, what their relationships are with third-party companies, how many claims they’ve reviewed that year and how many were approved or denied.
All this information later becomes ammunition if they deny the appeal, allowing the attorney and his client to potentially get around the “standard review” in a subsequent lawsuit, by saying the insurance company was unreasonable, had a conflict of interest, or other similar circumstances. If this type of information is not requested and doesn’t become part of the original claim file, the disabled claimant is forever forbidden from raising the issue.
The Importance of Medical Support
A claim file contains a minimum of 500 pages and up to thousands of pages, according to Greg Dell. But the key content that must be targeted is the medical support. Your attorney is honing in on the medical team review, which is either the nurse case review or one performed by a general or specialist physician. These reports are generally the underlying basis of the claim denial, says Cesar Gavidia.
One or more of these paid medical professionals have likely provided an opinion that the disabled claimant’s own records don’t support the stated restrictions and limitations. This can happen if the treating doctor fails to respond to Unum’s letter requesting a statement within a stated time period. Unum then takes this as, essentially, “agreement by silence.”
So, now that the insurance company has executed a claim denial and the policyholder has hired a disability attorney to handle the appeal, there is a 180-day ticking clock. The strategy comes together for building additional medical support through new doctors, additional testing, reviews and physician statements.
Customized Attending Physician Statements
The standard physician’s statement that comes from Unum for your doctors to fill out is typically a boilerplate document containing only one or two lines beneath each question. That’s all the space provided to answer what should be a detailed description of things such as the patient’s restrictions, limitations, symptoms and specific conditions. A customized attending physician’s statement from your own attorney will be much more thorough – and remember, this all goes in the official record that a future judge will see if the case ends up in court.
Another extremely important part of the doctor’s statement is the verification of the patient’s condition as it pertains to an ability to perform his occupation. This is rarely included in a Unum request for treating-physician information. If the restrictions and limitations aren’t applied to an inability to work, it becomes a strategy that the insurance company uses as a reasonable basis to deny a claim.
Ability to Perform
When it comes to the ability of a disabled claimant to perform work, it needs to be very specific, explains Greg Dell. It also must address whether the person is able to perform his “own occupation” or “any occupation.” Cesar Gavidia agrees and expounds on that issue by using the example of a dentist.
“We’ll be getting very specific in terms of the procedures they’re performing, the instruments they’re using, the time they’re spending on their feet, the time they’re spending sitting down, the specific maneuvers they must make their hands, and that type of thing,” says Gavidia, noting that it can all affect the ability of the dentist to perform substantial and material duties.
Then the case will swing to whether or not the person is able to perform “any occupation” that provides gainful employment. The insurance company could look at a wide range of jobs or occupations similar to the claimant’s former occupation, or one he may have performed in a prior job, or even something related to his education, training or experience.
It’s the job of the disability insurance lawyer to address all these issues and document why the person is unable to sit, stand, process, focus, multitask or perform any number of cognitive or physical functions. The intricacies of winning an appeal of a Unum denied disability must be brought about through a coordinated effort between the claimant’s doctors and his own personal statement as well as those from friends, family members and co-workers.
Between building up the medical, the occupation, the personal statement, bringing in statements from other people about what’s going on, and introducing medical literature or supportive medical studies, the average appeal can become several hundred pages by the time the attorney is ready for submission. It’s an art that takes a tremendous amount of skill and expertise.
“And that’s our biggest asset,” notes Greg Dell. “That’s the reason why you need a lawyer because unless we’ve done this before, there’s just no way that you could possibly gather every single thing. “
The attorneys at Dell & Schaefer delight in digging into a new claim and are always ready to discuss your occupation, medical conditions and how they may be able to help with an appeal to Unum or any other disability insurance company. Feel free to call Greg Dell, Cesar Gavidia or any other attorney at their disability insurance law firm. The initial consultation is always free, so reach out by phone or the contact button on the company website.