Our Client v. Unum Life Insurance Company of America
Our client developed ankylosing spondylitis (a painful inflammatory arthritis condition) that progressed over time, though he kept working as a production supervisor for a packing company for as long as possible despite his worsening condition. When it became too painful and began impacting his ability to complete his work and even daily activities, his doctor supported him as disabled and, after filing his claim, he initially received short-term disability benefits from Unum Life Insurance. But after paying his short term benefits, Unum denied his request for long-term benefits.
Unum’s long-term disability plans delegated to itself the authority to determine if someone qualifies for long-term benefits, so under ERISA the standard of review favored upholding its decision unless our client could show its denial was “arbitrary and capricious.” After being denied long-term disability benefits, the client retained our services and we helped him gather important medical and vocational evidence confirming his disability and submit it to Unum as part of his appeal. Unum did not conduct an independent medical examination, despite our client’s physician’s suggestion, opting to make its decision using only file reviews from in-house physicians. Following its review, Unum rejected our client’s appeal, and we sued to overturn Unum’s decision.
The court found that Unum’s assessment of our client’s health was arbitrary and capricious, citing that Unum refused to have the client physically examined, relied solely on its in-house file reviewer’s credibility determinations, relied exclusively on doctors in its own employ, and failed to meaningfully evaluate the medical evidence that our client presented. The court determined Unum’s review was “clearly inadequate” as it was “not based on a reasoned or rational reading of the record before it,” and ruled in our client’s favor, remanding the case and requiring that Unum provide a full and fair assessment of our client’s health. After the remand, we added even more evidence proving his disability and Unum approved his claim, paying him all owed benefits.
