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Unum Disability Denial With Medical Record Review Only

Can Unum deny disability claims and appeals by merely conducting paper reviews of a claimant’s medical records?

Yes, apparently they can.

It would seem logical that a court of law would advocate that an insurance company should be required to have a claimant examined by a qualified physician before coming to the conclusion that the claimant is not disabled.

Unfortunately, Unum’s failure to send a claimant for an IME, relying solely on paper reviews to make its determination to deny benefits, has been ruled as acceptable by an Indianapolis Court of Appeals, rejecting Plaintiff’s argument that the failure to send her for an IME was an abuse of discretion.

According to the court decision in this Unum lawsuit, “doctors are fully able to evaluate medical information from file reviews, balance objective data against subjective opinions of the treating physicians, and render an opinion without direct consultation with the claimant.”

In this case, the Plaintiff suffered from fibromyalgia, migraines and allergies which were severe and disabling according to several of her treating physicians. However, the Plaintiff chose to treat with doctors (who practiced alternative medicine) and did not treat patients according to “generally accepted medical standards” as set out in Unum’s Plan.

When her claim was initially denied by Unum, after conducting only a paper review of her medical records, Unum informed the Plaintiff that part of the reason for the denial was that she was not receiving regular medical care pursuant to generally accepted medical standards, as required by the Plan. The Plaintiff chose to continue treating with these doctors even after Unum informed her that this was a reason for their denial.

The court ruled in favor of Unum’s motion for summary judgment holding that Unum was entitled to arbitrarily disregard the Plaintiff’s physicians’ medical opinions that the Plaintiff was disabled and could not work and was allowed to make this determination based solely on a paper review.

The court disagreed with the Plaintiff’s argument that “the opinions of treating physicians deserve special consideration in benefits determinations.” The court’s holding was based on its determination that the Plaintiff made the decision to seek medical help from physicians who advocated alternative medicine, not generally accepted medical treatment for her fibromyalgia, migraines and allergies.

The court felt that if the Plaintiff had treated with standard medical providers (as required by her Plan) her claim that deference should be given to her treating physicians would be much stronger.

It is very important to review your policy language carefully before you choose doctors to treat you for your disabling condition as your policy may exclude treating physicians that practice alternative medicine.

Since Unum and other insurance companies alike are permitted to conduct paper reviews to make your claim determinations, it is extremely important to ensure that the doctors that you are treating with document your restrictions and limitations carefully, completely and correctly. But even more important is to choose doctors whose medical opinions will be given deference by the insurance company as well as a court of law.

It is not clear whether this claimant had legal representation prior the Unum claim denial. With appropriate legal representation and guidance it is possible that this claimant could have avoided a denial.

There are 2 opinions so far. Add your comment now.

Ken Lassesen:

Can you explain what “generally accepted medical standards” are to conditions where there is no standards?

For example: http://www.cdc.gov/cfs/management/index.html and http://www.cdc.gov/lyme/postLDS/index.html

Attorney Greg Dell:

Ken,

Good question. Please see this FAQ entry for a response.

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