Our client, Mr. B, formerly worked as a Plumber for a fabrication and manufacturing company. In January 2016 a number of medical issues, including chronic low back pain, lumbar spine radiculopathy, bilateral facet hypertrophy, and sciatica, forced Mr. B to stop working and submit his claim for disability benefits, first under his employer’s short-term disability (STD) policy and then continuing under its long-term disability (LTD) policy. Both benefits were funded and administered by UNUM. Mr. B’s occupation as a Plumber was physically demanding and required high level of exertional functioning. Under his employer’s disability policy, he would be considered totally disabled if he was unable to perform the material and substantial duties of his “regular occupation” as a Plumber.
After paying Mr. B for the maximum benefit period under the STD policy, UNUM denied LTD benefits on the basis that he allegedly no longer met the policy definition of disability. Specifically, UNUM determined that not disabled as required by the policy when he stopped working on January 2016.” After receiving the denial, Mr. B contacted Dell & Schaefer and discussed his case with Attorney Jay Symonds. Attorney Symonds identified several significant issues in UNUM’s denial letter and in the physician consultant’s medical reviews, and agreed to prepare and submit Mr. B’s ERISA appeal with the assistance of his appeal team.
The appeal addressed all of UNUM’s short-comings and reasons for denial, with a special focus on the review conducted by Hartford’s in-house medical consultant and peer review physicians. One of the focal issues was UNUM’s determination that Mr. B’s was not under the regular care of a physician when he stopped working, which was not correct. Rather, it was established that Mr. B was working and covered under the group policy when he was injured at work and fact that he was not able to first see his physician for 6 days did not negate coverage.
Approximately 7 weeks later, and after reviewing the appeal and hundreds of pages of exhibits and medical records, UNUM overturned its decision to terminate the claim and reinstated Mr. B’s long-term disability benefits.