Unum denies disability benefits to a Minnesota legal secretary with pre-existing condition

This is a case in which Unum’s decisions to deny benefits was consistent with the policy language. Employer-provided group disability insurance plans are different from individual plans. An employer-provided disability plan depends upon the employer/employee relationship. If something happens to interrupt this employer/employee connection it can have consequences, as Carol Jones discovered.

Jones had been a legal secretary with Fabyanske, Westra and Hart, P.A. when she was hospitalized in January 2004 for major depression. She filed a claim for disability benefits under the firm’s group long-term disability insurance policy issued by Fortis Benefits Insurance Company (Fortis). Fortis found that Jones was disabled, and after the three month qualifying period began paying long-term disability benefits.

She was cleared by her treating psychiatrist, Dr. Paul Richardson, to return to work after June 4, 2004. She disagreed with Dr. Richardson’s recommendations and notified Fortis that she was seeking a different psychiatrist. Meanwhile, Fortis suspended benefit payments on June 8 and notified Jones that they were going to review her eligibility. The disability insurance provider also asked for additional medical information.

Dr. Richardson modified Jones release to work. The modified work release recommended part-time beginning June 28 and full-time starting July 26. Jones returned to work part-time on the 28th as recommended, but she also scheduled initial appointments with two other psychiatrists, both of whom had refused to support her claim of continuing long-term disability without an office visit. She chose not to see these doctors a second time.

She stopped working on July 15 with the support of a third psychiatrist, Dr. John Heefner. She sent records from her visits to Dr. Heefner and the other two psychiatrists, to support her qualification for long-term disability benefits. Fortis notified Jones on August 26 that it was denying her long-term disability claim for benefits after June 7. The disability insurance company based the denial on her failure to satisfy the test of disability present in the Fortis policy.

Jones chose not to appeal this adverse decision and returned to work part-time on September 20, 2004. She began working full-time on October 4.

The Fabyanske firm changed their group disability insurance provider to Unum on January 1, 2005. Toward the end of February 2005, Jones quit working because of an infected dog scratch. She was terminated by the firm in mid-March. Later that same month, she filed a long-term disability claim with Unum. She gave her major depression and other ailments as the basis for her claim.

Unum denied the claim, using the pre-existing condition clause which stated that “in order to receive the payment you must satisfy the pre-existing condition provision under: 1. the Unum plan; or 2. the prior carriers plan, if benefits would have been paid had that policy remained in force.”

Unum had based its decision on the fact that Jones satisfied neither of these conditions. First she had received psychiatric treatment within the three months prior to the effective date of Unum’s policy, January 1, 2005, and her disability began within the first 12 months of that date.

Then Unum had looked at the Fortis policy to see if she qualified for coverage under its terms. Unum found that the Fortis policy defined a pre-existing condition as one that was diagnosed or treated during the three months before the claimant became insured. The policy also denied coverage for any disability that was caused by a pre-existing condition during the first 12 months after coverage under the policy commenced. And finally, Unum determined that Jones’ coverage under the Fortis policy had lapsed on August 26, 2004, the date that Fortis had issued its final decision that Jones was no longer disabled.

The insurance company deemed that her disability coverage had not resumed until she returned to work full-time in October 2004. Because Jones had received psychiatric treatment within three months of that date, Unum concluded that Fortis would not have paid benefits under the pre-existing condition clause of their policy.

Jones appealed. Unum contacted Fortis about the apparent lapse in coverage. After speaking with the Fortis claims agent who handled Jones’ prior disability claim, Unum adjusted the date when the policy lapsed to June 8. Unum called Jones and informed her that their decision to deny her claim was based on information gained from Fortis. They recommended that she contact Fortis, and let her know that their decision could change if Fortis changed its position.

Jones apparently contacted Fortis as recommended, because a Fortis agent called Unum and confirmed that Jones had fallen out of an eligible class when her disability ended, and she failed to return to full-time work. Based upon this information, Unum affirmed its decision to deny long-term disability benefits.

Unum long-term disability claim denial comes before District Court.

With the assistance of long-term disability attorneys, Jones took her case before the U.S. District Court of Minnesota, claiming she had been wrongfully denied benefits under the Employee Retirement Income Security Act (ERISA). Justice Joan M. Erickson granted summary judgment to Unum, finding that Unum had not abused its discretion in determining that Jones is coverage under the Fortis policy had lapsed between June 8 and October 4, 2004.

Justice Erikson issued her ruling based on what she felt was clear policy language. A covered person’s insurance ended when the person was no longer in an eligible class or when the person stopped active work. The policy went on to define what made a person eligible. An employee had to be working full-time, and as long as an employee worked at least 30 hours per week, the person would be considered full-time. Because Fortis had determined that Jones was no longer disabled on June 8, 2004, and she did not return to full-time work for almost 4 months, her insurance coverage under the Fortis plan had clearly lapsed.

District Court affirmation of Unum disability denial goes to Court of Appeals.

Jones’s disability insurance attorneys appealed the decision. For the most part, the Court of Appeals agreed with the District Court’s analysis, but this higher Court did observe some areas which they felt both Unum and the District Court had overlooked. Because Dr. Richardson had re-issued a limited release for work that began on June 28, and Jones returned to work on this date, her coverage under the Fortis policy would have remained in effect until she quit working entirely on July 15. Because she would have been released to work full-time on July 26, her lapse of coverage would have begun on that date.

The billing records reflected that Fortis had waived premium payments for Jones up until their final decision on August 26 to deny her long-term disability benefits. She was added back as an employee after she returned to work full-time in October. These records confirmed that her coverage had lapsed.

Disability insurance attorney presents arguments to refute lapse of insurance policy.

As part of the appeal, Jones disability insurance attorneys argued that her coverage had begun on April 2001, and that there was no lapse of coverage in 2004 because Fabyanske had continued to consider her a full-time employee on medical leave until she returned to work full-time. The Court found that while some insurance policies allow coverage until an employee is formally terminated, the Fortis policy clearly stated that disability insurance coverage ended when an employee was no longer an active, full-time employee. It was impossible to consider an employee who had not worked for several months as an active, full-time employee.

Jones’ disability attorneys argued that interpreting the 30-hour per week requirement literally would lead to absurd results, because an employee taking a day off for a vacation, a holiday or illness would lose coverage and be subject to the pre-existing condition provision upon returning to work. The Court saw no evidence that either Fortis or Unum applied such hard-line restrictions. In fact the record demonstrated otherwise. Jones had missed a week of work in November 2004 due to illness, and this was not counted against her.

Finally, Jones’ disability insurance attorneys argued that Unum had ignored the continuance of insurance clause in Fortis’ policy. This clause allowed Fabyanske to continue coverage for a person who was unable to perform active work because of a covered disability. In considering this argument, the Court noted that the clause expressly stated that “continuance must be based on a uniform policy, and not individual selection.” Unum had looked into this. Fabyanske informed Unum that the only formal leave of absence policy within the company was a family and medical leave policy.

In addition to this, the record indicated that Fabyanske was uncertain as to whether Jones was returning to work. A letter dated August 13, 2004 asked if Jones was returning. She stopped by the office several weeks later on September 3, saying she would attempt to return to work on the 8th, then left a message later, saying she wouldn’t be able to do so. The Court found that Jones’ disability insurance attorneys had failed to prove that Fabyanske had requested her coverage be continued or that it was Fabyanske’s uniform policy to do this.

Court chooses the familiar abuse of discretion standard to review Unum disability denial.

The policy granted Unum discretion to determine Jones’ eligibility for benefits and to interpret the terms and provisions of the policy. This meant that the proper standard of review was abuse and discretion, even if Jones’ disability attorneys argued for a heightened standard of review because of Unum’s past history. First, the Court found that Unum’s record had been clean for the two years following the agreement to review claims practices prior to 2003.

The Court also found that Unum had thoroughly investigated Jones’ claim twice, making every effort to apply the policy language from both its plan and the Fortis plan it had inherited. The Court agreed that the policy had lapsed by at least six weeks before Jones returned to work in October 2004, and the under the 12-month pre-existing condition clause, Jones was not covered under either the Fortis or Unum policies. The judgment of the District Court was affirmed.

This is one of the unfortunate situations that can arise because of the confusing and complex language insurance companies use in their plans. Before stopping work as Ms. Jones did, contact a disability insurance attorney. The extensive knowledge available from an experienced attorney could make the difference between retaining your disability insurance coverage and losing it.


Did you find this helpful?
Unhelpful (0)

Resources to Help You Win Disability Benefits

Disability Benefit Denial Options
Submit a Strong Appeal Package

We work with you, your doctors, and other experts to submit a very strong appeal.

Learn more

Sue Your Disability Insurance Company

We have filed thousands of disability denial lawsuits in federal Courts nationwide.

Learn more

Protect Your Benefits
Get Your Disability Application Approved
We help claimants throughout the entire application process.

Learn more

Prevent a Disability Benefit Denial
We manage every aspect of your disability claim following claim approval.

Learn more

Negotiate a Lump-Sum Settlement

Our goal is to negotiate the highest possible buyout of your long-term disability policy.

Learn more

Unum Reviews
(642)

Policy Holder Rating

1.6 out of 5
Read 60 reviews
0%would recommend
5
0%
4
0%
3
1%
2
55%
1
43%
Timely Payments
1.8out of 5
Handling Claim
2.1out of 5
Customer Service
2.1out of 5
Dependable
2.1out of 5
Value
1.9out of 5
Showing 8 of 642 Reviews
Unum

Low payments

Reviewed by Dorothy on November 30th 2023   Verified Policyholder | November 2023 date of disability
I was injured at work. I did house keeping in a hospital. I tore just about everything imaginable in my knee. I was let go from my job, because I was no longer able to do ... read more >
Unum

They closed my claim and I have been without income since they closed it

Reviewed by Mary C. on November 8th 2023   Verified Policyholder
Went off work on 9/26/22 due to back issues. Applied for Short Term Disability. On Jan 2023 switched over to Long Term Disability and Unum had me to apply for Social Secur... read more >
Unum

I feel like Unum is giving me the runaround!

Reviewed by Rachelle H. on May 11th 2022   Verified Policyholder
I have contacted UNUM multiple times since I’ve needed them. I feel like they are giving me the runaround! Please help!
Reply
Sent on May 11th 2022 by Attorney Stephen Jessup

Rachelle, the law provides certain timelines and deadlines with which to provide information or decisions. Please feel free to contact our office to discuss your situat... read more >

Unum

Unum terminated my benefits with no warning

Reviewed by K. Potter on September 9th 2020   Verified Policyholder
I was told I was covered with Unum through my employer (continuum). I got an email today for my termination, no prior talks of infractions with attendance, no warnings, no... read more >
Reply
Sent on September 9th 2020 by Attorney Stephen Jessup

K. Potter, termination as in your employment was terminated or a disability claim was terminated? If your employment was terminated and you had not filed a claim for di... read more >

Unum

I've been trying to care care of my Unum benefits for over a year. They’ve been so rude

Reviewed by Tracey W. on August 30th 2020   Verified Policyholder
I have been trying to take care of my Unum benefits for over a year. I’ve called and back in November I did appeal letter, they say they never received. I did everything... read more >
Reply
Sent on August 30th 2020 by Attorney Gregory Dell

Tracey, I am sorry to hear of your issues with Unum. We would love to learn more about your claim to see if we can get Unum to pay or if we can sue them with you. Pleas... read more >

Unum

I've paid for STD for 20+ years. Now, I'm actually sick and can't get paid

Reviewed by Natalie on June 29th 2020   Verified Policyholder
My employer uses unum for short-term disability. I was hospitalized back on june 13 and discharged on june 25. I was admitted for double pneumonia and hypoxia, which I end... read more >
Reply
Sent on June 29th 2020 by Attorney Rachel Alters

Natalie, hopefully your claim will be approved. If they deny the STD claim then you will need to appeal the determination.

Unum

Unum thought I was fine to work. I wasn't

Reviewed by Elizabeth L. on May 21st 2020   Verified Policyholder
48 yoa dentist POTs Dx aug 22. Attempted to return to work initially but got sick. Was going to go back 2 days/wk in September but could not. Then did go back part time as... read more >
Reply
Sent on May 21st 2020 by Attorney Stephen Jessup

Elizabeth, please contact our office to discuss the denial of your claim and your rights to pursue legal action against Unum.

Unum

Unum has made me feel like a criminal

Reviewed by Kevin on February 6th 2020   Verified Policyholder
Hi, I am currently receiving LTD from UNUM. I used to work as a Radiologist Tech at Vanderbilt Medical Center in Nashville, TN. for about 10 years. Than I started having g... read more >
Reply
Sent on February 6th 2020 by Attorney Gregory Dell

Kevin, I am sorry to hear all that you are going through and the stress this is causing you. The policy governing your claim likely does allow Unum to conduct an in-per... read more >

Answered Questions by Our Lawyers
(96)
Showing 8 of 96 Answered Questions

Q: Do we have any legal action against Unum?

Answered on January 15th 2024 by Attorney Alex Palamara
A: I am sorry to hear of Unum’s actions here and how they have treated your claim, especially in their long del... Read More >

Q: Is it normal for “UNUM” to ask for a police report?

Answered on January 15th 2024 by Attorney Alex Palamara
A: Derrick, a simple answer to your question is Yes, if there was some sort of MVA accident which caused or contr... Read More >

Q: Unum stopped my COLA benefits at age 65

Answered on December 19th 2023 by Attorney Rachel Alters
A: Unum policies usually only pay COLA increases until you turn 65 even if the policy pays longer. Read More >

Q: Survivor's benefits

Answered on December 15th 2023 by Attorney Gregory Dell
A: Cindy: A few things come to mind. Your disability policy will have a section called deductible sources of inco... Read More >

Q: FMLA and my LTD claim

Answered on December 6th 2023 by Attorney Gregory Dell
A: Unum doesn’t consider FMLA as they only care if you meet the terms of your disability policy with Unum. Read More >

Q: Is the recipient responsible for overpayment when they had nothing to do with the reporting?

Answered on November 30th 2023 by Attorney Gregory Dell
A: Jeanne:The beneficiary, which would be you, is responsible for a legitimate overpayment regardless of who ... Read More >

Q: Does UNUM periodically review Group Long Term Disability Insurance claims/payments? For example, do they verify medical eligibility every five or ten years?

Answered on October 24th 2023 by Attorney Gregory Dell
A: Great question. The answer varies on the type of claim you have. On average Unum reviews medical eligibility e... Read More >

Q: Unum is cross plan offsetting

Answered on October 15th 2023 by Attorney Alex Palamara
A: Tom, I am sorry to hear of this situation. Please contact us at 954-620-8300 so that we can learn more about t... Read More >
Helpful Videos
(875)
Showing 12 of 875 Videos
Disability Benefit Tips
(330)
Showing 8 of 330 Benefit Tips

Is UNUM a Good Insurance Company?

One common question the attorneys here at Dell Disability Lawyers receive comes from policyho... Read More >

How Long Does UNUM Long Term Disability Last?

When it comes to long term disability (LTD) insurance, every UNUM disability insurance policy... Read More >

Can You Sue UNUM?

If UNUM denies your long term disability insurance claim, can you sue? Generally, t... Read More >

How Does UNUM Define Disability?

UNUM Group - the Tennessee-based Fortune 500 insurance company that includes UNUM US, UN... Read More >

Beware of Traveling While on Disability with Unum

In the past several months our office has been hired by two separate clients who had individual disability policies purchased privately throug... Read More >

If I Sue Unum for a Disability Insurance Denial, What Should I Anticipate?

Disability insurance Attorneys Gregory Dell and Stephen Jessup discuss the numerous issues th... Read More >

Unum Disability Benefit Denial Trends, A Legal Perspective

In this video we discuss the recent trends they have observed with regard to Unum Insurance C... Read More >

A New Bait and Switch Tactic by Unum Disability Insurance Company

Unum reached a new low today which displays absolute disregard for the rights of a UNUM insured. Our law firm advised Unum in a January 16, 20... Read More >
Dell Disability Cases
(373)
Showing 8 of 373 Dell Disability Cases

Transportation Manager with Brain Injury Wins Unum Disability Benefit Appeal

Unum unjustly terminated our client’s long term disability claim after it had approved and... Read More >

Louisiana State College Director Wins Unum LTD Appeal But Then Denied Again

Client was Regional Director for the State of Louisiana. She was diagnosed with cervical rad... Read More >

Unum Approves LTD Benefits for Pharmacist with Eye Disorder

Rachel Alters of Dell Disability Attorney’s currently represents an Ambulatory Operations P... Read More >

Billing Manager With Back Disorder Wins Unum Long Term Disability Denial Appeal

Despite suffering with chronic knee and back pain for 7 Years, Unum still needed to be convi... Read More >

Unum Lifts Mental Health Limitation on Disability Claim

When our client first contacted our office and spoke with Attorney Stephen Jessup her claim for long term disability benefits had been approve... Read More >

Unum Approves Long Term Disability Application to a Program Manager

Our client, a high level Program Manager for a large international aeronautics company, was involved in an automobile accident that resulted i... Read More >

After appeal filed by Attorney Jay Symonds, UNUM overturned previous denial of long term disability benefits for South Carolina Nurse

Our client, Ms. L, formerly worked as a Registered Nurse for a nursing home. In November 2014 a number of chronic physical conditions and pain... Read More >

Unum Overturns Original Decision to Deny Benefits to Disabled Account Manager Following Appeal Submitted by Dell Disability Lawyers Appeals Team

In 2016, Sarah, an Account Manager, began suffering severe abdominal pain accompanied by bloody diarrhea. The frequency and condition was so s... Read More >
Disability Lawsuit Stories
(765)
Showing 8 of 765 Lawsuit Stories

Unum Wrongfully Terminated Disabled Lawyer’s Disability Claim of Depression and Anxiety Despite Improvement in His Condition

This Unum lawsuit and appeal in federal court is a great victory for all Unum disability claimants. This ca... Read More >

Court Rules Plaintiff's Medical Records Was Replete With Evidence Supporting Claim of MS & Was Not A Pre-Existing Condition

BackgroundIn Bayer v. Unum Life Insurance Company of America, C.A. No. 18-9702 (E.D. LA 2020), Plaintiff began working as a seni... Read More >

After paying for 13 years Unum Denies Disability Benefits to Woman with Lyme Disease and Endometriosis

In Stephanie Dorris v. Unum Life Insurance Company of America (Unum), Plaintiff was President of Beans Plus, Inc... Read More >

Inexperienced Lawyer Handles Unum Disability Lawsuit and Fails to Provide Evidence to Support Occupational Argument

The case of Stephanie Dorris v. Unum Life Insurance Company of America (Unum) is an example of how an inexperien... Read More >

Can UNUM Deny LTD Benefits When Plaintiff Proves Eligibility by a Preponderance of the Evidence?

In the case of Paul Luu v. First Unum Life Insurance Company of America (Unum), Plaintiff had been employed by MUFG Union Bank ... Read More >

Is Remand Required If Plaintiff Proves Disability by a Preponderance of the Evidence?

In Ralph Dewsnup v. Unum Life Insurance Company of America (Unum), Plaintiff was a trial attorney with the law firm of&nbs... Read More >

Can Unum Deny My LTD Benefits After Paying For 15 Years?

In the case of Michael J. Christoff v. Unum Life Insurance Company of America (Unum), plaintiff was a partner in the firm ... Read More >

Court Rules Proper Standard of Review is Abuse of Discretion

In Christoff v. Unum Life Insurance Company of America, Plaintiff Christoff suffered from severe fibromyalgia. He was insured under a group em... Read More >

Reviews from Our Clients

Request a Free Consultation

Our Lawyers Respond Same Day

5 Ways We Help Get Your Benefits Paid

Get Your Disability Application Approved

Our goal is to get your application for disability income benefits approved. Applying for disability benefits can be a difficult process and the information you provide is critical. Most disability insurance companies look at your application in hopes of finding a reason to deny your claim. Your disability company will ask you to complete numerous forms, interview you, request lots of information, speak with your doctors and possibly request to have you examined by their "hired gun" doctor.

Through our experience of having helped thousands of disability insurance claimants, our lawyers will guide you through the entire application process and give you the best chance to get your disability claim approved the first time.

Submit A Strong Appeal Package

If your disability insurance benefits have been wrongfully denied, then our lawyers know exactly what it takes to get your disability claim approved. You only get once chance to submit an Appeal, therefore every piece of evidence that will support your disability claim must be included. The goal is to win your disability benefits at the Appeal level, but while preparing your Appeal you must consider how a federal judge will review your disability claim if your benefit denial is upheld.

Preparing a strong disability appeal package is an art that requires you to understand how the courts interpret your disability policy language, ERISA regulations / laws, and how to strategically present evidence in support of your definition of "disability". We encourage you to contact any of our lawyers for a free immediate review of your disability denial.

Sue Your Disability Company

98% of the disability insurance lawsuits filed by our law firm have resulted in either the payment of benefits or a lump-sum settlement agreement. Our disability lawyers have filed ERISA governed and private policy long term disability insurance lawsuits against every major disability insurance company in state and federal courts nationwide and we love fighting for the "little guy" against the multi-billion dollar insurance company giants.

We have recovered hundreds of millions of dollars for our clients and we would like the opportunity to provide you with a free review of your disability benefit denial. There are many complex factors in a disability benefit lawsuit and the legal battle to win long term disability benefits can be fierce.

Prevent A Disability Benefit Denial

Approval of long-term disability is a continuous process as every disability insurance company will evaluate your eligibility for benefits on a monthly basis. You can never let your guard down and assume that your disability company will continue to pay your benefits for as long as you think you need them.

Our law firm offers a reasonable flat fee monthly claim handling service in which we handle every aspect of your long-term disability claim and do whatever it takes to make sure you are paid every month.

Negotiate a Lump-Sum Settlement

Let's discuss if a lump-sum settlement or buyout of your disability insurance claim is both available and makes financial sense for you. Our lawyers have negotiated more than five-hundred million dollars in disability insurance buyouts and we know how to get you a maximum settlement. A disability insurance company is not required to offer a buyout and not every disability company offers them.

Questions About Hiring Us

Who are Dell Disability Lawyers?

We are disability insurance lawyers that know how to get your short or long term disability benefits paid. As a nationwide law firm we have helped thousands of disability insurance claimants throughout the United States to collect hundreds of millions of dollars of disability insurance benefits from every major disability insurance company.

In more than 98% of our cases, our lawyers have been able to either get our clients paid monthly disability benefits or obtain a one-time lump-sum settlement. Our lawyers have seen it all when it comes to disability insurance claims and we know exactly what it takes for your disability claim to be approved.

We welcome you to contact any of our attorneys for a free immediate review of your disability claim. We also invite you to visit and subscribe to our YouTube channel where we have more than 700 videos and regularly provide tips to help protect your disability benefits.

Who do you help?

Our lawyers help individuals that have either purchased a long term disability insurance policy from an insurance company or obtained short or long term disability insurance coverage as a benefit from their employer. We have helped individuals in almost every type of occupation with monthly disability benefit payments ranging from $1,500 to $50,000.

Our clients include all types of employees ranging from retail associates, sales representatives, government employees, police officers, teachers, janitors, nurses, pilots, truck drivers, financial advisors, doctors, dentists, veterinarians, lawyers, consultants, IT professionals, engineers, professional athletes, business owners, and high level executives.

A strong understanding and presentation of the duties of your occupation is essential for securing disability insurance benefits.

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 phone, email, fax, GoToMeeting 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 800-698-9159 or by email. Lawyers 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.