Dr. Karen M. and her North Carolina disability attorney filed a lawsuit against UNUM in the United Stated District Court for the Eastern District of North Carolina to acquire her long term disability benefits. The beneficiary of disability benefits under a plan provided through her employer Private Diagnostic Clinic PLLC at Duke University Medical Center, Dr. Karen ceased working as a general practitioner on February 23, 2007.
Dr. Karen suffers from “severe cognitive dysfunction that included executive function, memory loss, peripheral neuropathy, gait disturbance (impaired tandem gait), and abnormal reflexes” as the result of several medical conditions that includes “Vitamin B 12 deficiency, Vitamin D deficiency and sleep apnea.”
UNUM arbitrarily decides that claimant is no longer disabled
Diagnosed with “neurocognitive syndrome,” Dr. Karen can no longer indent and diagnose diseases and prescribe treatments, making her totally disabled from performing her own occupation as a physician or any other occupation. Dr. Karen submitted a claim for long term disability to UNUM on May 26, 2007 and began receiving her disability benefits as expected. On July 7, 2009, Dr. Karen was informed that her disability benefits were being terminated as UNUM had determined that she no longer was disabled. Dr. Karen appealed this decision and was denied that appeal on December 10, 2009.
On October 12, 2010, UNUM stated that Dr. Karen no longer was entitled to her UNUM Life Insurance Premium Waiver as well. She again appealed and was denied that appeal on June 24, 2011. Having no options available to make use of her UNUM policy, Dr. Karen hired a disability lawyer and filed a lawsuit under ERISA (the Employee Retirement Insurance Security Act of 1974) and U.S.C. § 1132. Under these provisions, Dr. Karen’s attorney claims that UNUM wrongfully denied Dr. Karen her long term disability benefits in violation of her plan terms and conditions in that Dr. Karen is unable to work and the insurer did not properly evaluate Dr. Karen’s claim and ignored the credible evidence provided that verified her disabled condition. According to Dr. Karen’s disability attorney, UNUM “falsely attempted to claim that [Karen’s] condition is a behavioral health condition subject to the ‘mental illness limitations,’ section of her policy, using this as a basis to evade Dr. Karen’s severe cognitive dysfunction and memory loss” problems. Thus, UNUM has violated its contract with Dr. Karen.
Claimant was also denied her life insurance premium waiver by UNUM
In their second claim, Dr. Karen and her attorney accuse UNUM of denying Dr. Karen’s Life Insurance Premium Waiver benefit by ignoring evidence of Dr. Karen’s total disabled condition and again ascribing Dr. Karen’s symptoms to a mental illness, which is an inaccurate assessment of her condition. They accuse the insurer of not conducting a full and fair review of Dr. Karen’s claim as dictated by law, and allege that UNUM violated its “contractual obligation to waive Dr. Karen’s life insurance premium payments as stipulated in her plan.”
Consequently, Dr. Karen and her attorney ask the District Court to:
- Grant Dr. Karen declaratory judgment and find her disabled and entitled to long term disability benefits from UNUM;
- Grant Dr. Karen declaratory and injunctive relief and find her entitled to her insurance plan’s waiver of premium benefit;
- Order UNUM to reimburse Dr. Karen for reasonable attorney’s fees; and
- Order the insurer to pay any other relief deemed appropriated to compensate for the damage she has sustained as a result of UNUM’s termination of her disability benefits.