Unum Disability Beneft Denial Overturned for Pre-textual Investigation

Insurance companies hire physicians to comb through medical files to look for a reason to deny an ERISA disability benefit claim. In a Texas case, Unum was criticized for not making relevant medical records available and for not basing its decisions on concrete medical evidence. Unfortunately, it is impossible to know what information is provided for those independent medical record evaluations without challenging those disability benefits denials.

In a case against Unum Life Insurance Company of America, the claimant worked as a carpenter for eleven years. In the summer of 2003, he suffered a work-related back injury. Even though doctors performed six surgeries on the plaintiff’s back over the next three years, the claimant continued to have severe pain.

Before the fourth operation, his doctors found that he was disabled and was unable to perform the duties of any gainful employment. He couldn’t lift any object of more than 30 pounds. He couldn’t frequently carry objects greater than 15 pounds. He couldn’t sit or stand for longer than one hour without rests. As a result, he made an ERISA claim for long-term disability benefits under a Group Disability Policy his former employer maintained with Unum Life Insurance Company of America (“Unum”).

After paying benefits for several years, Unum denied the claim. Unum based its decision to deny disability benefits on an internal investigation of the claim. Specifically, Unum relied on a report from an independent medical record evaluation performed by one of its internal physicians, Dr. Tsourmas.

But he issued two reports that were irreconcilable. Dr. Tsourmas initially determined in July 2006 that the claimant should qualify for disability benefits, but, before he would form a definitive opinion, he would like to review an earlier MRI of the claimant’s back. Two months later, Unum advised Dr. Tsourmas that the requested MRIs were unavailable – though the MRIs were already in Unum’s file – and asked that he promptly assess the claimant’s then functioning level. Without seeing the claimant or receiving new medical evidence, Dr. Tsourmas issued an addendum to his original report, opining that the claimant was employable and re-trainable.

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