Long Term Disability Claimant Wins Against Unum Provident.

What can you do if your disability insurer disclaims coverage for your long term disability claim?

Well, as one policy holder found, you can sue, and win. In this case, the insured sued because the infamous Unum Provident disclaimed coverage for his long term disability claim. Unfortunately for the insurance company, the claimant happened to have read his policy (he was an attorney), and took issue with their disclaimer all the way to the Second Circuit (federal appeals court).

In a scathing decision, the appeals court reversed the lower court and found that the administrator of the Plan (Unum) had a conflict of interest because it had both the discretionary authority to determine the validity of the disability claim, and paid the benefits under the policy; found that a reasonable person would conclude that the insurer's denial of long-term disability was arbitrary and capricious; and granted benefits and interest running from September 18, 1995, the date on which defendant-insurer rejected plaintiff's appeal.

Some of the Court's findings are interesting: For example, the Court found the reasons given for rejecting the information was unreasonable and deceptive because other evidence of the claim submitted by the doctors would have revealed a plethora of details about why this poor man could not work as a tax attorney for Sotheby's. Essentially, the nurse's rejection of the medical evidence "mischaracterizes the quality and detail of the evidence . . .submitted on appeal."

Indeed, First Unum never told the insured that they had rejected the application because one portion of the appeal did not have the physician's signature. Citing Juliano v. Health Maint. Org. of N.J., Inc., 221 F.3d 279, 289 (2d Cir. 2000) (finding an insurer's failure to communicate the reason for denying coverage sufficient evidence to warrant de novo review of the administrator's decision under our old standard). The Court criticized the insurance company for implying that it would have been pointless to undertake any efforts to sort out the obvious and facial discrepancies in his record by "hiding behind a terse initial response to a set of questions it posed three months earlier. Essentially, they ignored the evidence they didn't like and relied heavily upon evidence that was inconclusive of his disability.

Had he been told what their problem was, the insured would have "had no trouble addressing First Unum's undisclosed and uninvestigated concerns." Moreover, First Unum never explained how he could continue to perform the material duties of a tax lawyer despite these restrictions, and compounded its "deception" by representing that the records reviewed by their physician, when, in fact, no records were reviewed by a physician.

Apparently, this was not the first time that this insurance company was slapped on the wrist by a federal court. The opinion refers to at least 30 other cases).

The bottom line-- don't always believe what the insurance company says, and call your New York insurance lawyer.

UNUM PROVIDENT - AN INTRODUCTION TO PROBLEMS WITH THIS "INCOME PROTECTION" COMPANY

Introduction to UNUM Long Term Disability Scheme "We can protect your income and help to preserve the lifestyle of you and your dependants." This is the UNUM sales pitch which leads people to believe the payments they make will protect them financially if their physical/mental health takes a turn for the worst. How wrong one can be. Please read my story carefully and protect yourself from a future of misery, physical/mental suffering and financial hardship. I will be naming and shaming Louise Vaughan, Stephen Brown, Stuart Lewis, Lizz Keirnan and Christine Taylor. These people employed all kinds of tactics in an attempt to refuse my claim - including advising me to take steps which would effectively make my claim null and void. Also they employed a private detective to invade the privacy of my family and I. Including camping outside my parent's house for 3 days, reporting the movements of my family, taking pictures, video and most disturbingly breaking into my car to read my private letters.

Letter to help you get your complete CIGNA or LINA file

I have a number of cases against Life Insurance Company of North America (LINA or CIGNA). As you know one of the first things you do when appealing a denied disability claim is request the entire file from the insurance company. LINA does not always send the entire file in response to such a request. To assist you in getting the complete file I have prepared a letter in which I identify the documents that I expect to find in a LINA file. I then tell LINA which of those documents I received and which documents I did not.

Dr. Fantasia finds fibromyalgia Plaintiff disabled

Whaley v CNF Transportation, Inc. Long Term Disability Plan, C. A. No. 03-363 (Southern District of Ohio (Order Granting Plaintiff's Motion For Judgment On The Administrative Record (June 14, 2005))

In Whaley, Judge Thomas M. Rose found that the Defendant claims administrator abused its discretion. Dr. Fantasia, Plaintiff's chiropractor, opined that Plaintiff was disabled. That was the extent of Dr. Fantasia’s role. However, Dr. Fantasia’s name alone rates a headline.
Whaley was diagnosed with fibromyalgia. She completed a Daily Activities Questionnaire (“DAQ”) and an Employee Assessment Report (“EAR”). After completing those two forms, Ms. Whaley provided various doctor reports indicating she was disabled. The DAQ was 13 months old and the EAR was 11 months old on the date the claims administrator denied the claim.
Judge Rose found that the claims administrator abused its discretion in denying Plaintiff’s benefit claim. Judge Rose reasoned that, since the claims administrator had more current evidence from Whaley’s doctors at the time of the denial, at the very least it should have obtained updated DAQ’s and EAR’s at the time it denied Whaley’s claim.

Court awards $300,000 in COBRA penalties

Penalties for COBRA notice violations can be substantial.
A federal court in Nebraska recently
imposed penalties of over $300,000 plus attorneys
fees. Delcastillo v. Odyssey Resource Management Inc., 320 F. Supp. 2d 889 (D. Neb. 6/11/2004). Here, the court found that the participant and his family suffered particularly severe consequences as a result of the lack of health care coverage.

CANCER TOPS MOST FREQUENT CAUSES OF LONG TERM DISABILITY CLAIMS

According to UNUMProvident, the leading provider of disability insurance, the following are the five leading causes of long-term disability claims:

12 percent – Cancer
10 percent – Complications of pregnancy
10 percent – Joint/muscle/connective tissue diseases
9 percent – Back injuries
8 percent – Cardiovascular disease

Labor Employment Law Blog: Federal Disposal Rule

You need to make sure that your disability lawyer has a shredder or has contracted with a shredding service to dispose of your medical records when they are no longer needed. Often lawyers make extra copies of your medical records and do not use them in your case. This new statute requires that the attorneys have a "disposal policy."

We have a shredder for small jobs-5 pages at a time or less. We have also hired a shredding service to take care of the big jobs. The shredding service provides a free locked bin for us to fill. At the end of each month, or earlier if we fill the bin, they take the bin and destroy the medical records. All ERISA disability firms should be doing something similar.

Thanks to Sheppard Mullin and the laboremploymentlawblog.com for bringing this to my अत्तेंशन.