The UNUM Life Insurance Company of America (UNUM) is one of the largest providers of long term disability insurance in the United States; however, UNUM is not only well known for its size. This disability insurance company has a checkered history with regard to its handling of Unum disability Claims. In 2004, Unum was the subject of an investigation by state regulators which resulted in a reassessment of 200,000claims and a fine in excess of $15 million. Unum entered into a regulatory settlement agreement that was a joint effort with 46 different states. Despite Unum’s regulatory settlement agreement, there have been subsequent cases around the country in which Unum has been accused of unfair denials, delayed payments of benefits and reliance on flimsy evidences to either deny or terminate a legitimate claimant’s disability benefits.
The case of Domingo Gopez v UNUM Life Insurance Company of America filed recently at the District Court for the Central District of California by a disability attorney is an example of a Unum claim denial.
The Nature of the Complaint
The plaintiff Domingo Gopez was a custodian employed by the Capistrano School District. Gopez, on January 1st 1995, was issued a disability insurance policy by UNUM which was part of an employee benefit plan that was offered by the Capistrano School District. This case is not governed by ERISA as the plaintiff worked for a government entity. Under the terms of the policy, the insured was to receive monthly disability income protection worth 60% of the insured’s monthly income up to a maximum of $2000 per month in the event the insured became totally disabled as a result of injury or sickness. The benefit was payable for five years provided the disability began prior to the insured’s age of 64 years.
In order to receive disability benefits under the policy, the insured had to be “unable to perform with reasonable continuity the substantial and material acts necessary to pursue your occupation in the usual customary way”. And to continue receiving disability benefits after the initial 24 months of payable benefits, the insured had to demonstrate that he is also “unable to engage with reasonable continuity in another occupation in which you could reasonably be expected to perform satisfactorily”¦”
The nature of the plaintiff’s job required him to have sufficient physical ability that included lifting, carrying, pushing pulling, walking long distance around the campus, bending, squatting and reaching. All these activities can range from medium to heavy intensity. The plaintiff last day of work was on January 15th 2008. Prior to becoming disabled, the plaintiff had a history of shoulder pain due to work related injuries. This resulted in surgeries on both his shoulders with the latest surgery occurring on January 17th 2008. Consequently, the plaintiff wasn’t able to return to work after this surgery.
Because of his disability, the plaintiff filed a claim for disability benefits with UNUM. As required under the terms of the policy, the plaintiff filed his claim in a timely manner supported with a magnitude of medical records documenting his shoulder pain and surgeries that resulted from this condition. These supporting documents also included agreed medical examination reports from the plaintiff’s Worker’s Compensation case with the most recent dated September 10th 2008. The report stipulated that the plaintiff was not permitted to do “heavy lifting over 25 pounds on a repetitive basis, 50 pounds on an occasional basis and overhead work with the right and left shoulder.” In addition to the supporting medical documents, the plaintiff also included in his claim a statement from his employer that it could not accommodate the plaintiff’s work restrictions.
Despite the overwhelming medical evidences supporting the plaintiff’s disability, UNUM rejected the plaintiff’s claim on August 15th 2009. UNUM based its unreasonable denial by categorically selecting certain evidences taken out of context and at the same time ignoring the mountain of evidences of the plaintiff’s disability. Although the plaintiff was approved for the much stricter and narrower standard of disability used by Social Security Administration (SSA), UNUM also choose to disregard this information. In addition, in the plaintiff’s worker compensation claim and independent doctor determined that the plaintiff was totally disabled.
Legal Redress Sought through the Lawsuit
As the result of UNUM’s breach of its contractual obligations, the plaintiff had suffered monetary damages, mental and emotional distress leaving the plaintiff no choice but to seek relief through the Court with this legal action against UNUM. In the lawsuit, the reliefs sought by the plaintiff included:
- Damages for failure to provide benefits under the disability policy including interest and consequential damages
- General Damages for mental and emotional distress and other incidental damages
- Exemplary Damages in an amount appropriate to punish and make an example of UNUM’s actions
- An award of reasonable attorney fees and costs
- Any other relief which the Court may deem just and proper