Our client contacted us in November of 2014 shortly after she had received a denial letter from Unum which denied her continued receipt of Long Term Disability (LTD) Insurance Benefits. Prior to receiving the November 5, 2014 denial letter, our client had received LTD benefits since early 2011.
In June of 2010, our client was forced to leave her occupation as a Nurse Practitioner for Genesis Consolidated Services, Inc. She was forced to leave her position due to very serious medical conditions which limited her from performing the material and substantial duties of her regular occupation as well as any gainful occupation for which she was fitted by education, training or experience. Her conditions included: Mast Cell Activation Disease, Mitochondrial Myopathy, Fatigue, Fibromyalgia, Arthralgias/Myalgias, Chronic Pain Syndrome, Peripheral Nerve Disease, Neuritis, Postural Orthostatic Tachycardia, Syncope and Collapse, Dyspnea upon Exertion, Chest Pain, Bilateral Forearm Tendinitis, Bilateral Hand Pain and Weakness, Cervical Spine Muscle Spasm, Lumbar Spine Muscle Spasms, Left-Sided Sensorineural Loss, Tinnitus, Headaches and Migraines, Hypertension, Hyperlipidemia, Abdominal Pain, Gastroesophageal Reflux Disease (GERD), Vomiting and Diarrhea, Gastroparesis, Vitamin D Deficiency, Erythromelalgia, Urinary Tract Infection and Cognitive Decline.
Thankfully, her employer provided an ERISA Group long term disability policy in case sickness or injury prevented her from performing her occupation or any occupation. Because she was unable to continue to work due to the aforementioned conditions and because she was a covered employee under the policy, our client made a claim for LTD benefits in late 2010. Unum reviewed the claim and agreed to pay her LTD benefits which effectively commenced in January of 2011.
Unfortunately, her receipt of LTD benefits ended when she received the aforementioned November 5, 2014 denial letter. In this denial letter, Unum claimed that she was no longer disabled under the terms of the policy because it believed she had the ability to perform the duties of any gainful occupation for which she is reasonably fitted by education, training or experience. In support of this contention, Unum relied upon an internal physician’s review who concluded that she was capable of performing full-time sedentary work. Additionally, Unum alleged that one of her own treating physicians agreed that she was capable of this full time sedentary work. As such, Unum concluded that this Nurse Practitioner no longer qualified for continued LTD benefits and denied her claim beyond November 5, 2014.
Dell & Schaefer Gets Involved
Within hours of receiving the denial letter from Unum, this Nurse Practitioner contacted Dell & Schaefer and spoke with Attorney Alexander Palamara. A quick review of the denial letter coupled with a discussion with the Nurse Practitioner made it abundantly clear that Unum’s decision was blatantly wrong. After the initial consultation, Dell & Schaefer agreed to take on her case and fight to get her back on claim.
Review of the Claim and the Filing of the Administrative Appeal
Upon being hired to take on the case, Attorney Palamara immediately ordered a complete copy of Unum’s complete claim file so that he could see what exactly Unum relied upon to deny the claim. A review of the file showed that Unum was relying heavily on an internal file review that was conducted by one of its own employees. Beyond this biased review, Unum also relied upon a document where it had asked one of our client’s treating physicians whether he believed our client was capable of full time sedentary work. While a box was check marked yes, there was no signature on this document so the validity and reliability of it was questionable at best.
After completing the review of the claim file and gathering updated medical records, an administrative appeal was timely filed by Attorney Palamara. This appeal heavily criticized Unum’s reliance upon the internal file review as well as the check mark purported to be by her treating physician. Attorney Palamara pointed out that less than one month prior to this alleged “sedentary work” check mark, this treating physician stated that he could not comment on work restrictions and recommended a Functional Capacity Evaluation. The administrative appeal questioned why Unum would not have a FCE conducted and instead rely upon this checkmark by a hand doctor who could not furnish an opinion one month earlier. The appeal also focused on the overwhelming support our client had from all of her other treating physicians. These doctors agreed and opined that “within a reasonable degree of medical certainty, (our client) was unable to perform the duties of any gainful occupation for which she was reasonably fitted by education, training or experience.”
By way of a letter dated July 15, 2015, we received word that Unum had made a determination that she remains eligible for benefits and that its previous decision was incorrect. Our client’s claim is thus being reinstated and all past due benefits are being sent immediately. We are ecstatic that Unum saw the error in its ways and agreed to overturn its wrongful denial. Now back on claim, our client knows that our firm will continue to do whatever it takes to see that she remains on claim until she is able and ready to return to work or until her policy expires at age 65.
If you have been denied disability benefits by Unum or any other disability insurance company, please do not hesitate to contact Attorney Alexander Palamara at Dell & Schafer for a free consultation.