Federal Court Reverses Unum’s Denial of Long-Term Disability Benefits

The case of Arturo J. Otero v. Unum Life Insurance Company of America has an extensive procedural history going back to 2005 when Otero first applied for disability benefits due to his atrial fibrillation. He had a contentious bout with Unum at that time and returned to work on a part-time-basis in 2010. He continued to pay premiums to Unum for disability coverage.

In February 2013, Otero filed a new claim for long-term disability. His atrial fibrillation condition has worsened and he could no longer work even part-time. Unum fought very hard in its attempt to avoid paying Otero benefits and denied his claim. After exhausting his administrative remedies, Otero filed a lawsuit in the Alabama federal district court under the provisions of ERISA. Ultimately, in a 68-page opinion, the court sided with Otero and concluded that this was a new claim, not a reopening of the old claim, and that Otero was entitled to long-term disability benefits.

Standard and Extent of Review

1. Court concludes de novo review is appropriate.

Unum argued that the court should give its denial decision deference and not reverse its decision unless the court found Unum acted arbitrarily and capriciously. The court disagreed and, after reviewing the entire administrative file, even going back to Otero I, held that the court “will not defer to a non-decision that occurred as the result of the mechanical expiration of time as opposed to the actual exercise of administrative discretion.”

The district court then determined its review would be de novo. This means it could make its own decision without deferring to any decision made by Unum during its evaluation of the claim through its administrative review.

2. Documents to be included in court’s review.

The court noted that despite Unum’s argument that the review should be limited to documents in the administrative record and the court should not consider new evidence presented by Otero, Unum also presented documents that were not part of any administrative record. Finally, Unum was forced to agree that, under the de novo standard of review, the court was “not limited to the facts available to the Administrator at the time of the determination.”

3. The court reviewed this as a new claim and not a reopening of the old claim and referenced the current case as Otero II.

“The current claim that Dr. Otero was disabled as of February of 2013, more than six months after the termination of his prior claim, means that the court treats this claim as a new disability claim under the terms of the policy, even though it is based on a recurrent condition.”

Disability Under the Terms of the Policy

The proper standard for evaluation was not how Dr. Otero performed his duties with the group he was working for prior to his disability. According to Unum’s policy, the proper evaluation was “how the job is performed in the national economy.” Since Otero’s atrial fibrillation condition prevented him from working 40 hours a week or taking call, he was disabled from working in his own occupation.

Evidence Otero lost 20% of his income.

The policy required Otero to present evidence that he suffered a 20 percent loss in “indexed monthly earnings” for the three years preceding his February 2013 claim for disability. Unum asserted that the administrative record lacked any evidence of the loss so Otero’s claim for disability must be denied.

After a detailed discussion of evidence that was or was not in the administrative record, evidence Otero should have supplied but failed to do so, and evidence Unum should have asked Otero to supply, but failed to do so, the court concluded:

“While Dr. Otero could have done a better job of providing the relevant documents, because Unum did not address his claim, did not provide a basis for denying the claim, did not specifically request the W-2 forms, and did not clarify the issues, his confusion about what documents were key is understandable. Under these circumstances, the court will not allow Unum to take unfair advantage of the confusion that it created when the lack of information resulting from that confusion is remediable.”

The court remanded to Unum to obtain the missing W-2 forms.

Court’s Final Order

1. Unum waived its right to challenge Otero’s eligibility for coverage due to his part-time work when it continued to accept premium payments from Otero. Therefore, Otero was covered under Unum’s disability policy.

2. As of February 2013, Otero was unable to perform his regular occupation as a neurologist.

3. If, on remand, proper calculations determine that Otero’s income decreased by 20 percent as of February 3, 2013, Unum is required to pay him long-term disability benefits. Unum was given 45 days to provide the court its final determination of the claim.

Although this case was not handled by our office, we believe it can be instructive to those struggling to obtain disability benefits for a second claim for long-term disability benefits after returning to work and once again becoming disabled. Whatever stage you are at with your disability benefits, feel free to call us at Dell & Schaefer for a free case evaluation.

» More Unum disability insurance claim cases.

DISABILITY INSURANCE COMPANY INFORMATION
Videos, Questions, Resolved Cases, Lawsuit Summaries & Company Reviews

disability insurance companies complaints

View videos, articles, resolved cases and claimant reviews about your specific disability insurance company.

Leave a comment or ask us a question

FAQ

Do you work in my state?

Yes. We are a national disability insurance law firm that is available to represent you regardless of where you live in the United States. We have partner lawyers in every state and we have filed lawsuits in most federal courts nationwide. Our disability lawyers represent disability claimants at all stages of a claim for disability insurance benefits. There is nothing that our lawyers have not seen in the disability insurance world.

What are your fees?

Since we represent disability insurance claimants at different stages of a disability insurance claim we offer a variety of different fee options. We understand that claimants living on disability insurance benefits have a limited source of income; therefore we always try to work with the claimant to make our attorney fees as affordable as possible.

The three available fee options are a contingency fee agreement (no attorney fee or cost unless we make a recovery), hourly fee or fixed flat rate.

In every case we provide each client with a written fee agreement detailing the terms and conditions. We always offer a free initial phone consultation and we appreciate the opportunity to work with you in obtaining payment of your disability insurance benefits.

Do I have to come to your office to work with your law firm?

No. For purposes of efficiency and to reduce expenses for our clients we have found that 99% of our clients prefer to communicate via telephone, e-mail, fax, GoToMeeting.com sessions, or Skype. If you prefer an initial in-person meeting please let us know. A disability company will never require you to come to their office and similarly we are set up so that we handle your entire claim without the need for you to come to our office.

How can I contact you?

When you call us during normal business hours you will immediately speak with a disability attorney. We can be reached at 800-682-8331 or by email. Lawyer and staff must return all client calls same day. Client emails are usually replied to within the same business day and seem to be the preferred and most efficient method of communication for most clients.

Reviews

Bruce R. (Arizona)

Steve Dell has done an exceptional job with my disability application process. The firm is extremely well managed. They have acquired an incredible amount of experience over many years. I recommend them for disability insurance claims without reservation. 

Don (Florida)

I called this firm a few months ago completely disparaged due to a company cutting off disability benefits at a time that nearly caused me to lose everything.

Attorney Alex Palmera and Danielle worked hard to reach an amicable settlement and my case was settled a few months later. This is a good firm and the specific expertise in disability claims saved me countless hours of hassle at a time when an already fragile state existed.

Thank you Mr. Palamara and Danielle.

Sandra B. (Arkansas)

I have nothing but good things to say about how my buyout was handled with my disability claim. The level of professionalism was amazing. All of my questions and concerns were answered either by Danielle L. or Alex P. in such a timely manner and with such care I would recommend them in a heartbeat to anyone needing to approach their provider with buyout options.

They did a fantastic job communicating between the provider and me, always keeping my best interest at heart and always answering my many many questions. They really did take most of the stress out of this whole situation. I would give them a 10 out of 10 for every step of this crazy journey. Thank you so much for helping me through this.

Brenda R. (New York)

I needed assistance with an appeal for a LTD claim that was initially denied. Stephen understood what needed to happen to win the appeal and he did win the appeal for me.

Michael C. (Virginia)

Greg Dell and his assistant Anneli have been extremely responsive and helpful, not only our initial consultations, but in follow-ups 1 and 2 years later with the insurance company to ensure that they comply with their agreements (which they did), as well as a separate and only slightly-related inquiry about our health insurance. I always hear back from them very quickly, which is rare and greatly appreciated.

Jeff P. (Oklahoma)

After a very long and frustrating ordeal to keep my LTD payments coming I decided to seek assistance from and attorney. After much research and asking those in the legal profession Dell & Schaefer seemed to be the top choice. I reached out and Alex Palamara was the attorney assigned to my case. All I can say is the experience was outstanding. Both Alex and his Paralegal, Danielle Lauria were excellent to work with. They were very kind, concerned, understanding of my frustrations and treated me with the utmost respect. Communication was excellent with regular updates and telling me what I could expect in each stage of the process.

Alex was also very straight forward with what to expect and no pie in the sky promises or expectations were made. In the end we won our case and I believe it was solely due to their experience and knowledge of not only the laws but the insurance companies as a whole. I would highly recommend them and am very grateful for the help they afforded to me.

Chad B. (Illinois)

I originally spoke with 3 other long term disability lawyers about my case before contacting Dell and Schaefer. None of those law firms would take it. They said the chances of me winning was not good. After finding Dell and Schaefer online I spoke with one of the attorneys that has since left. He did take my case but later it was picked up by Rachel Alters. Rachel is amazing and a very intelligent attorney. She not only won my case but also was able to get my back pay for 6 months.

I also cannot say enough about Sonia Nogueira. Sonia was always quick to answer any of my questions. I would usually hear back from her within hours of sending her a email. I do not know where I would be if I hadn’t contacted them. My family and I cannot thank them enough. Don’t let an insurance company tell you they are not responsible for paying you. I paid them for 20 years monthly and they looked for any reason they could not to have to pay me when I needed my benefit. Thank you Rachel and Sonia for all you guys do.

Paul L. (New York)

Words can only scratch the surface regarding my experience working with Attorneys Dell & Schaefer. It’s a very emotional experience making the decision to utilize disability insurance. The unknowns were/are scary. From the very first phone call, the support staff was/are very professional and reassuring. I have been working with Attorney Steven Dell for approximately 10 years. He is confident, reassuring, listens to and addresses all my concern, and is extremely dilligent in understanding my specific policies for how they impact me. It is very reassuring that Steven handles and deals with the insurance company on my behalf. Attorney Dell’s team, and specifically Merlin, Attorney Dell’s assistant, is simply fantastic. Her professionalism and attention to detail have made all my communications with the office seamless.

Simply put, my experience with Dell & Schaefer made the emotional rollercoaster experience of my neck surgery seem like a walk in the park.

Thank You, Thank You, Thank You, to both Attorney Steven Dell and to Merlin for how you have helped me over these past 10 years.

Dilligence, Reassurance, Professionalism at every step, Confidence, Results.

With 10 years experience with working with Dell & Schaefer, taking that step to call Attorneys Dell & Schaefer was one of the best professional and personal decisions I have ever made.

You want to know what you can do – the below comment about posting your first name and last name initial on our website. Put up my full name, phone number, and email address. I will gladly speak to anyone about your office and tell them my story and how instrumental Steven and Merlin have been in my life over the past 10 years.

Speak With An Attorney Now

Request a free legal consultation: Call 800-682-8331 or Email Us