After appeal filed by Attorney Jay Symonds, UNUM overturned previous denial of long term disability benefits for South Carolina Nurse
Author: Attorney Jay Symonds
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 forced Ms. L to stop working and submit her claim for disability benefits first under her employer’s short term disability (“STD”) Policy then continuing under her employer’s Long-Term Disability (“LTD”) Policy both benefits were administered and funded by CIGNA. Under her employer’s long term disability policy Ms. L would be considered totally disabled after 12 months if she was unable to perform the duties of any gainful occupation, which was defined as an occupation that is or can be expected to provide her with income at least equal to her gross disability benefit.
After paying Ms. L for the 12 month own occupation period under the LTD Policy, UNUM denied further LTD benefits on the basis that she allegedly no longer met the policy definition of disability. Specifically, UNUM determined that Ms. L was able to perform the duties of other gainful occupations. After receiving the denial, Ms. L contacted Dell & Schaefer and discussed her case with Attorney Jay Symonds. Attorney Symonds identified several significant issues in UNUM’s denial letter and in the evidence it relied on and agreed to prepare and submit Ms. L’s ERISA appeal with the assistance of his appeal team.
The LTD appeal addressed all of UNUM’s short-comings and reasons for denial, with a special focus on the medical records on and around the date of UNUM’s denial. The appeal next addressed the fact that UNUM’s medical reviewers incorrectly relied on purported surveillance footage and investigative reports of Ms. L performing certain basic activities. The appeal made clear that while there are extreme cases where surveillance activity is so inconsistent with a claimant’s reported limitations that a simple viewing of the surveillance may constitute sufficient evidence that is clearly not the case with Ms. L. The activities noted were not inconsistent with her established and stated level of functional abilities as reported to UNUM. Similarly, her purported activities (i.e., driving; pumping gas) were not outside the range of activities for someone incapable of sedentary work. Sedentary work generally involves two hours of standing or walking and six hours of sitting in an eight-hour work day. Although Ms. L was observed engaging in activities outside of her home, this activity did not establish that she was actually able to perform sedentary work. Specifically, the surveillance footage did not speak to her ability to sit/stand/walk/lift/carry on a regular and sustainable basis 8 hours/day 5 days/week for 52 weeks/year. What’s more, there was nothing in the claim file to confirm or even suggest that either of UNUM’s in-house medical record reviewers actually watched the surveillance video, instead relying on a written report. Thus any reliance on the surveillance was incorrect and unreasonable and was not evidence of a full, fair, thorough and honest review of Ms. L’s claim.
Two months later, and after reviewing the appeal and hundreds of pages of exhibits and medical records as well as the expert reports, UNUM overturned its decision to terminate benefits, paid full LTD back benefits and reinstated Ms. L’s LTD claim. Attorney Symonds continues to represent our client to best ensure that CIGNA will not terminate his benefits again. Feel free to call our disability attorneys for a free consultation on this or any matter relevant to your disability claim.