An insurance company will not pay long-term disability benefits without some sort of assurance your condition is as dire as you claim. And the insurer will rarely take the claimant’s word for it. Every insurance company has in-house physicians, nurses and investigators to challenge each aspect of a disability claim. What you say to your own doctors, employers or others could come back to haunt you. The recent case against Unum Life Insurance Company of America provides a classic example.
An “Any Gainful Occupation” Definition of Disability
The claimant worked as a licensed physical therapy assistant at Tampa General Hospital, where he was covered under a group disability policy issued by Unum Life Insurance Company of American (“Unum”). The policy provided for two types of benefits – short-term benefits for disability payments in the first two years and long-term benefits for disability payments beyond the first two years. To qualify for ongoing benefits after 24 months of receiving disability payments under the policy, the claimant had to prove an inability to perform the duties “of any gainful occupation.” The policy defined gainful occupation as “an occupation that is or can be expected to provide you with an income at least equal to 60% of your indexed monthly earnings within 12 months of your return to work.”
The claimant sought benefits in December 2005 after suffering pain in his hip. A lack of blood supply to his hip caused him, earlier that year, to undergo two bilateral hip replacement surgeries. Doctors restricted the claimant from “any and all physical and mental work.” Unum approved the claim and made the disability benefit payments.
Unum periodically checked on the claimant’s condition. In each conversation, the claimant confirmed he was disabled from any work. He advised Unum his physicians told him “not to lift or carry, push or pull greater than twenty pounds” and that the restriction prevented him from working as a physical therapist because the job required moving patients. He reported his pain was constant and ranged from stiffness to throbbing pain. He further reported he probably could never return to work.
Unum Investigation Uncovers Claimant’s Injury Is Not So Disabling
When Unum investigated his ability to work in any gainful occupation, the insurance company learned the following from his doctors and former colleagues:
- The claimant went on a month-long trip to Chile, Argentina and Uruguay three months after his disability benefits began.
- The claimant went on another extended cruise to an undisclosed location in 2006.
- The claimant underwent guardian ad litem training and worked as a volunteer.
- The claimant went on an extended trip to London and Spain in the Spring of 2006.
- The claimant regularly did laundry, prepared meals, went grocery shopping, exercised, put on his shoes, watered plants, and played bridge.
- The claimant’s doctors stated he had no limp, used no support, and could normally go up or down stairs without using a rail.
Based on these discoveries, Unum studied the jobs for which the claimant was suited. A vocational rehabilitation consultant concluded that the claimant could work as a museum scheduler, dispatcher or customer service representative – all of which would pay over 60 % of what he made as a physical therapy assistant. For this reason, Unum denied the claim.
Court Finds Unum Denial Is Supported
The claimant challenged the denial, raising numerous medical problems he continued to face. The Eleventh Circuit Court of Appeals – Florida’s highest federal court – upheld Unum’s actions and found that Unum had a reasonable basis to deny the claim.