General surgeon files lawsuit against Provident Life and UNUM for disability benefits award
Author: Attorney Cesar Gavidia
Having failed to uphold its obligation to provide disability benefits to one Provident Life and Accident/UNUM policyholder, the insurer now finds itself in litigation to solve the matter. A General Surgeon and his disability attorney filed a complaint on July 11, 2011 in an effort to pursue the disability benefits he is entitled to under his UNUM insurance plan.
Alleging damages for the non-payment of disability benefits, the physician and his disability lawyer have sought help from the United States District Court of the Middle District of Florida, Tampa Division. The pair have requested that the Court order UNUM to fulfill its obligations by paying the physician his entitled disability benefits, consequential damages, emotional distress damages, attorney’s fees, and other damages; and they demand a jury trial per Fed.R.Civ.P. § 38(b).
Doctor Seeks Disability Benefits from UNUM on Three Policies
The physician, a general surgeon since 1973 has three UNUM policies, each containing terms and conditions for the payment of disability benefits should he become disabled and unable to perform his job as a general surgeon. In the complaint, the physician and his lawyer explore the history of Provident Life, which is a subsidiary of UNUM, with both company’s duty-bound to fulfill all obligations under policies sold before and after their affiliation with one another. According to the history that the physician and his attorney show, they determined that “[d]uring the time from 1995 forward, defendants instituted a number of practices intended to manage claims on Provident individual disability insurance policies to avoid full payment of benefits due.” When Provident became a part of UNUM, the physician’s policy was and continues to be managed by that insurer, and according to the attorney, UNUM continues to try to avoid paying certain benefits to the physician as well as other similarly situated claimants.
Background of Doctor’s Disabling Condition
The physician was diagnosed with renal disease in January 2000 and filed a disability claim with his insurer, which claim was honored for his short-term disability payments. And, after moving to Florida in 2001, he returned to work on a part time basis as a gastroenterologist, but never returned to his general surgery practice. After being involved in a class action suit that attacked Provident and UNUM for an earlier litigation matter involving duplicity, the physician asked the insurer to reassess his claim in 2005 to retrieve his unpaid, entitled disability benefits. During the 2000 reassessment process, the physician’s claim for residual benefits was concealed and he only discovered this concealment when he ask UNUM to reassess his individual claim. The class action settlement agreement required the insurer to reassess claims in 48 states; among those claims was his. “Under the terms of the settlement agreement that led to the re-assessment, the claim by (the physician) was tolled until defendants denied it by letter dated July 10, 2006.” With an obligation to inform him of the state of his policy and the fact that residual benefits were a part of his plan, UMUM concealed this from the physician and misrepresented him his rights to pursue a residual benefits claim from 2000-2006 when he received a denial letter.
The physician had until June, 17, 2006 to pursue his claim, and he did, in fact, submit his claim for Residual Benefits before the June 17, 2006 deadline. The insurer did not ask for additional proof of loss. The physician provided his proof of loss within the 90-day period to do so, making that deadline of September 16, 2006. All was taken care of as far as he was aware of. Unfortunately for the physician, UNUM has refused to pay his entitled residual disability benefits that should have been paid from April 1, 2000 through June 14, 2006 in the amount of $3,950.00 per month for the 5-year and 2-month period plus appropriate inflation, AIB and interest adjustments, which has led to the filing of this complaint.
Allegations that UNUM Breached Its Contract to Pay Disability Benefits
In the compliant, the physician and his disability attorney allege that UNUM breached its contract with the doctor. They ask that the District Court declare that the physician “submitted adequate proof of income loss” and deserves “relief to establish coverage under the Residual Benefits clause” of his policy. And, they allege that UNUM breached its implied covenant of good faith with the doctor. Consequently, they ask for policy relief, damages, attorney’s fees and other damages, and that the case be heard by a jury.