A disability attorney recently instituted a lawsuit against the UNUM Life Insurance Company of America (UNUM) at the District Court for the District of New Jersey of behalf of a disabled client. In Robert Garozzo v UNUM Life Insurance Company of America and RTP Technology Corporation long term disability plan, the plaintiff Robert Garozzo is seeking payment of disability income benefits from UNUM under the terms of a long term disability Benefit plan.
The Nature of the Allegations
The plaintiff Robert Garozzo was a Project Manager employed by RTP Technology Corporation. As a project manager, the duties of the plaintiff’s occupation required him to handle several projects at the same time and work under extreme stress. In addition, he was also required to stand when making sales presentations and troubleshooting computer systems on-site. As an employee for RTP Technology Corporation, the plaintiff participated in an Employee Welfare Benefit plan that was issued by UNUM. The plan identified RTP Technology Corporation as the Plan Administrator and UNUM as the Claims Administrator. Nevertheless, besides being the Claims Administrator, it was alleged that at all times that UNUM was the fiduciary of the plan and administered, negotiated, funded, interpreted and maintained the Plan.
Under the plan, UNUM promised to pay qualifying RTP employees disability benefits if they were defined as being disabled under the plan. The Employee Welfare Benefit plan issued by UNUM defined “Disability” as:
You are limited from performing the material and substantial duties of your regular occupation due to your sickness or injury; and
You have a 20% or more loss in your indexed monthly earnings due to the same sickness or injury.
After 24 months of payments, you are disabled when Unum determines that due to the same sickness or injury, you are unable to perform the duties of any gainful occupation for which you are reasonably fitted by education, training or experience.
Claim for Long Term Disability (LTD) Benefits
On July 1st 2009, the plaintiff was in an accident in which an All Terrain Vehicle which he was riding flipped and rolled over on top of him. As a consequence of the accident, the plaintiff suffered multiple injuries which culminated in the plaintiff developing Deep Vein Thrombosis. This resulted in the plaintiff having to undergo a surgery to place a Gunther Tulip Inferior Vena Cava filter designed to trap emboli before they reached the pulmonary artery. According to the lawsuit, during hospitalization, the plaintiff began experiencing episodes of syncopal phenomena attributed to orthostatic hypotension, a form of low blood pressure that occurs when a patient stands up from sitting or lying down. The plaintiff is said to continue experiencing symptoms of lightheadedness and syncope to this day.
As a result of the disability that the plaintiff was suffering from, he filed a claim for LTD benefits with UNUM under the plan in December 2009. A Round-table review was held on January 25, 2010 during which UNUM approved the claim after concluding that the plaintiff was disabled from performing the duties of his occupation as a Project Manager. Subsequently, LTD benefits were paid to the plaintiff retroactive to September 29th 2009.
Reversal of UNUM’s decision to pay LTD benefits
On January 25th, February 11th and March 10th 2010, UNUM decided to review the plaintiff’s disability status and assigned its on-site physician who was certified in two specialties completely unrelated to the plaintiff’s impairments to review the plaintiff’s case. The onsite physician and UNUM’s Designated Medical Officer later concluded that the plaintiff was not precluded from performing the duties of a project manager on a full time basis. This conclusion was reached despite a contradicting medical opinion given by the plaintiff’s attending physician. On April 16th 2010, UNUM denied LTD benefits to the plaintiff based on the opinion of the on-site physician and Designated Medical Officer. No explanation was given as to the difference of opinion between the plaintiff’s attending physician and UNUM’s consultant doctors.
The plaintiff, in the light of UNUM’s decision to terminate his benefit, submitted an ERISA appeal to UNUM on October 11th 2010. Together with the appeal was a questionnaire and reports of the plaintiff’s treating vascular surgeon. The treating vascular surgeon reevaluation of the plaintiff was that the plaintiff continued to suffer from chronic venous thrombosis and venous insufficiency and concluded that the plaintiff was incapable of working in an occupation that require long periods of standing on the part of the plaintiff. This was because long periods of standing will cause increased swelling and worsen the plaintiff’s symptoms. It was noted in the lawsuit that the treating vascular surgeon’s opinion was never sought by UNUM when it made its initial determination to terminate the LTD benefits of the plaintiff.
The appeal also contained the medical records and statement of the plaintiff’s treating primary care doctor who agreed with the treating vascular surgeon’s opinion that the plaintiff “does not have the capacity to perform an occupation that would require significant standing on a continuous or consistent basis because it would exacerbate his symptoms of swelling and pain in the legs.”
Nevertheless, UNUM’s medical consultant disagreed with the plaintiff’s treating primary care doctor’s opinion. Consequently, based on a vocational review on November 22nd 2010, UNUM on December 17th 2010 informed the plaintiff of its decision to reaffirm the denial of LTD benefits to the plaintiff.
The plaintiff alleged in the lawsuit that UNUM’s unlawful actions included:
- Terminating the plaintiff’s disability claim in April 2010 without a reasonable basis and contrary to the evidence.
- Attempting to reduce its liability on the plaintiff disability claim by knowingly conducting a biased investigation of the plaintiff’s claim.
- Failing to adopt and implement reasonable standards for proper investigation of claims.
- Violating their own claim manual procedures in the handling of the plaintiff’s claim.
- Terminating the plaintiff’s disability claim in April 2010 without any evidence that his medical condition had improved from the time that they had begun paying him disability benefits.
- Failing to conduct a thorough, fair and objective evaluation of the plaintiff’s medical condition before terminating his disability benefits in 2010.
- Intentionally relying on biased medical reviews to support its pre-ordained termination of benefits in 2010.
- Failing to fairly, reasonably and promptly pay the plaintiff even though payment is warranted.
- Unreasonably terminating the plaintiff’s benefits and refusing to pay disability benefits due and owing to the plaintiff in violation of the Policy contract terms.
- Knowingly and/or recklessly disregarding ongoing medical proof submitted by the plaintiff that rebutted UNUM’s contentions that the plaintiff was not disabled as of April 2010 and onward.
- Failing to accord the plaintiff’s interests under the Policy the same faithful consideration UNUM LIFE gave its own financial interest.
- Failing to give equal weight to evidence submitted by the plaintiff’s treating vascular surgeon and treating primary care doctor.
- Looking for ways to discontinue making payments to the plaintiff.
Relief Sought in the Lawsuit
As a result of UNUM’s unreasonable behavior and breach of fiduciary duty, the plaintiff is seeking the following relief from the Court:
- An Order directing UNUM to reinstate benefits to the plaintiff under the plan.
- An Order requiring UNUM to award the plaintiff total disability benefits due and owing to him under the plan from April 16, 2010, to the present, with an award of pre-judgment interest.
- An Order requiring UNUM to award all past benefits due to the plaintiff under the plan including all annual and other increases, with an award of pre-judgment interest.
- An Order declaring that the plaintiff is to continue to receive disability benefits in the future for so long that the plaintiff continues to qualify for benefits under the plan.
- Payment of reasonable attorney’s fees and costs incurred in this action
- And other legal and equitable relief as the Court deems appropriate.