California Federal Court Finds Man Disabled, Overturns Unum’s Decision that denied Long Term Disability Benefits
Author: Attorney Alex Palamara
A former Assistant Sales Manager for HSBC was forced to leave work on May 14, 2008. This claimant suffered from constant low back pain due to spinal stenosis, disc bulges and protrusions, spondylosis at the L3-L4 and L4-L5 interspaces with T2 signal loss in the discs and disc space narrowing. The claimant described his constant pain like “the point of a bayonet into his back” that was “made worse by prolonged sitting, standing, or even a basic movement such as twisting…” Due to his pain, the claimant had tried several medications such as meloxicam, soma, oxazepran, Norco and hydrocodone.
This claimant was unique due to the fact that he was covered under two separate Unum long term disability policies. The first was a group disability insurance policy that he got through his employment at HSBC. He also had an individual policy that he purchased on his own separate from his employer’s policy.
Shortly after leaving work due to his conditions, the HSBC employee made a claim for long term disability benefits under both policies. While one policy was an ERISA governed policy and the other an individual policy, the definitions of disability (what it means to be disabled under the policies) were very similar in both policies. The ERISA group policy defined disability as follows “you are limited from performing the material and substantial duties of your regular occupation due to your sickness or injury…” The individual policy defined it as “a disability that renders you unable to perform with reasonably continuity the substantial and material acts necessary to pursue your usual occupation in the usual and customary way.”
While the definitions of disability were similar, Unum’s decisions under them were quite different. In fact, Unum approved the claim for disability benefits under the individual policy, but found the claimant was not disabled under the ERISA long term disability policy. This was done even in light of the fact that Unum had the same information for both claims. The portion of Unum that handled the individual policy found that his medical documentation was sufficient to find him disabled. Unfortunately, the portion of Unum that handles ERISA long term disability claims found the same information to be insufficient.
After filing administrative appeals challenging Unum’s decision that were also denied, an ERISA disability lawsuit was filed in the Northern District of California. In its decision on the case, the Court noted that there was substantial evidence in the record to support the limitations imposed by several doctors including an independent medical evaluator hired by Unum. Each of these doctors restricted the claimant from walking, sitting or standing continuously for no more than 30 minutes at a time. The Court found that this was sufficient to preclude him from performing his occupation. The Court also discounted surveillance conducted by Unum that showed him “driving a couple of hours to a cat show and showing cats during the day.” The Court noted that this surveillance did not cause Unum’s independent medical evaluator to alter his findings that the claimant was limited to semi-sedentary work.
Accordingly, the Court found the HSBC employee disabled under the terms of the ERISA Long Term Disability Policy and awarded him benefits.
If you have been denied benefits by Unum or any other disability insurance company, please do not delay and please contact Attorneys Dell and Schaefer for a free consultation and review of your claim.
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