Unum Disability Claim Tips for Physicians
Our law firm has extensive experience filing and litigating Unum disability claims for physicians. Our disability insurance attorneys understand how Unum operates and what it takes to file a successful Unum disability claim, and are happy to set up a free consultation to discuss your particular Unum claim.
Below are some answers to the most common questions our attorneys receive from physicians about the disability claim process, generally, and their Unum disability benefits, specifically.
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1. Does Unum still sell disability insurance policies to physicians?
Unum no longer sells private disability insurance policies to physicians, but remains a major player in the disability insurance industry as it continues to “administer” physician policies that it previously issued.
Our attorneys have litigated matters where Unum has tried to save money by aggressively “managing” physician policies, with the goal of denying or terminating claims to reduce payouts from this closed block of business.
2. I have a Paul Revere/Provident policy; why is Unum handling my disability claim?
Unum has multiple affiliated disability insurance companies. Your disability claim may be investigated and administered by Unum if your policy was issued by any of the following disability insurers:
- Paul Revere
- Colonial Life
- First Unum
3. How do I know if I have an “own occupation” policy/claim?
“Own occupation” policies pay benefits if you can no longer work as a physician, as compared to “any occupation” policies that only pay benefits if you are not able to work at all. Our attorneys have found that some older Unum policies have the most favorable “own-occupation” language that should protect you if you are unable to practice. These policies are also known as “true own-occupation policies,” and they provide more protection to physicians when compared to newly issued policies.
If you are a physician with a Unum disability policy, you most likely have a “own occupation” policy, and you may even have a specialty-specific policy.
A specialty-specific disability policy pays benefits if you cannot perform the duties of your particular specialty (for example, surgical anesthesiology, orthopaedic surgery, obstetrics and gynecology/OBGYN, etc.). In some instances, you can go back to work in a different capacity as a doctor, as long as you do not go back to work in your specialty. However, you generally must prove that, prior to disability, you were only practicing in your medical specialty, and not engaging in other types of work.
Some disability insurance policies sold to physicians, including Unum policies, are hybrid policies. Hybrid policies only provide “own-occupation” benefits for a limited period of time, and then convert to an “any occupation” standard for the rest of the benefit period.
4. How do I file a disability claim with Unum?
In order to file a Unum disability claim, you must submit the proof of loss required under your Unum policy. Most Unum policies require this proof to be submitted in writing and within a certain time frame—typically within 20 or 30 days from the date of loss.
The first step is obtaining and submitting Unum’s initial proof of loss packet, which will consist of several forms for you to complete and sign, including an investigative authorization, along with a form for your doctor to complete and sign.
Unum makes most of its forms available online, but Unum still sells several different types of group disability coverage, so you will want to make sure you are completing and submitting the right proof of loss packet for your particular claim.
You can also call into Unum to request the proof of loss packet and receive assistance locating the packet that fits your claim. However, if you call in, our attorneys have observed that Unum may subject you to an impromptu interview, knowing that you are not yet represented by an attorney.
If you are planning on having an attorney represent you on your claim, it is better to obtain the forms online and/or have your attorney contact Unum, so that you are not subject to questioning without your legal representative present.
5. Do you have any tips for filling out Unum disability claim forms?
Insurance forms are complex and contain trick questions, and disability insurance forms are no exception. Physicians often come to us asking “Do I need to fill out this part of the form/can I leave this question blank?” “Why is the company asking for this? It doesn’t apply to me.” Or “Why are they asking for my taxes/asking about my finances?” While insurers are entitled to investigate your disability claim, most initial paperwork is overly-broad and in some instances it may be appropriate to skip certain questions.
That being said, as your claim progresses, your analyst will be conferring with a team of attorneys and other consultants to identify any deficiencies in your responses. Fear of this happening can sometimes prompt physicians to over-share and provide too much, irrelevant information. So there is a delicate balance between failing to prove up your case by offering up too little information and potentially overcomplicating your claim by providing too much information.
Below are a few tips to review before completing your Unum claim forms:
1. Read your entire policy before answering any questions. If you do not know how your policy works, you will not understand why certain questions are being asked. And if you don’t understand the “why,” it is easy to prejudice your claim by providing too much or too little information.
While there are legal requirements that require insurers to refrain from misleading policyholders, courts also expect you to have read and understood the contract you are filing a claim under. Accordingly, relying on Unum or anyone associated with your disability insurance company to hold your hand is a bad idea. You need to be informed and proactive about protecting your interests from the start.
2. Be mindful of each form’s significance in the scope of the entire claims process. Generally speaking, the initial proof of loss packet is the most important set of claim forms because it sets the tone for your entire claim. Claim analysts are trained to review these forms to help determine your occupational duties under your policy, the extent of your restrictions and limitations (including the severity, frequency and duration of your symptoms, and possible job modifications), what additional information is needed, how your claim should be characterized under the policy (e.g. partial v. total disability, injury v. sickness, etc.), and what additional steps should be taken when investigating your claim in light of the policy’s requirements and limitations.
It’s also important to keep in mind that, unlike other insurance claims, disability claims require ongoing, monthly proof of loss to continue to qualify for benefits. Consequently, you will be completing other forms and submitting additional information on an ongoing and frequent basis, particularly in the first several years of the claim.
Each time you submit additional information or forms, claim analysts are trained to identify any inconsistencies with prior information in the claim file. If there are inconsistent answers, this undermines your credibility and can cause your claim to be flagged for heightened review and possible denial or termination.
3. Read each question carefully, and read each form through at least one time before answering any of the questions. Most disability paperwork is divided by topic, and each section often has specific instructions that can be easy to miss.
For example, at the outset of the claim, many forms will ask to you answer certain questions based on the facts immediately prior to your disability, since that is the timeframe that is generally the most critical in a disability claim. Some questions may ask for you to list employment or medical information from prior timeframes, while others may be more focused on your current employment status or current symptoms.
Timelines are particularly critical in disability claims. Analysts determine your “occupation” and categorize claims based upon your pre-and-post-disability work history and activities. Most claims also involve several other key dates that determine whether your claim is subject to preexisting condition limitations, whether you timely filed proof of loss, what your prior income should be for purposes of partial disability calculations, and the list goes on. If you create confusion regarding your claim’s medical or occupational timeline, it can lead to significant delays and, in some instances, denials that can only be sorted out through lawsuits.
4. Review your answers to make sure you have not been too sparse or generic. If you have not been involved in a disability claim before, the scope and nature of some of the questions can seem overly intrusive. Over the years, we’ve become involved in several claims where a physician reviewed the paperwork, did not understand why certain information was being asked, skipped those questions, and returned partially completed forms. This inevitably leads to frustrating delays, as insurers typically refuse to move disability claims forward unless/until they receive all requested information.
If you do not understand a question or why certain information is being requested, or are concerned that answering a question may expose you to legal liability, you should not answer without consulting with an attorney first. However, if you are refusing or failing to provide relevant information, you are not only giving the insurer an excuse for delays, but potentially making it easier for the insurer to deny your claim.
Insurers often rely on medical and other consultants to determine whether a claim should be paid. If, for example, you do not provide sufficient details and documentation regarding the precise nature of your condition, it makes it much easier for the insurance company’s doctor to conduct a cursory “file review” and determine there is insufficient information to verify disability. Similarly, if you refuse or fail to provide occupational information, it opens the door for your insurer to misconstrue your occupation and/or refuse to pay benefits until you submit the relevant financial information needed to determine your potential eligibility for benefits.
Sometime it is also appropriate to go beyond the bounds of the form if your particular situation is nuanced and the questions asked within the four corners of the claim form do not provide adequate context for your claim. However, you should be cautious about providing too much information, as this can also confuse issues, delay the processing of your claim, and prejudice your ability to collect benefits (see Tip #5, below).
5. Review your answers to make sure you have not been too detailed or specific. Keep in mind that the insurance company designed the form you are completing. It is has likely gone through several revisions (with attorneys and risk management professionals) and has been fine-tuned to elicit responses that can be used to limit or deny payment. So each time you answer a question, you should be considering the specific basis for the question and whether you are oversharing information that can be used against you.
For example, some forms contain open-ended questions designed to prompt you to provide additional details about your personal life that can later be used to make it easier for the insurer to look you up online, find family member’s social media accounts to see what they are posting about you, etc. The company may ask about your daily schedule, and if you give a lot of details, breaking your days down hour-by-hour, you are just providing them with a roadmap to give to their investigators if they decide to conduct in-person surveillance on your claim. Or the form might ask about your “hobbies,” or give you a list of activities (unrelated to your occupation) and ask you to identify what you can and cannot do. These responses are then used to determine if you have any interests or activities that they could argue are inconsistent with your reported limitations.
As another example, the volume of financial information that is relevant in a partial disability claim is typically significantly larger than the financial information that is relevant to a total disability claim. However, oftentimes insurers will request everything as a matter of course, which can lead to unnecessary delays and oversharing of personal financial information that can be used against you.
Many questions in this vein are largely irrelevant fishing expeditions, if you are filing a total disability claim under an “own occupation” policy (as opposed to an “any occupation” policy). However, it can be difficult to parse through the relevant and irrelevant without the aid of an experienced disability insurance attorney, and if you repeatedly refuse to provide relevant information, that can be a legitimate basis for a claim denial. So if you are concerned about the scope of questioning, it is advisable to contact a disability attorney before submitting anything (if you do not already have one).
6. Re-read all your answers to ensure they are accurate. Once you sign and submit your responses to the insurance company, your insurer (and courts) will hold you to those responses. Like other insurance forms, disability paperwork includes fine-print stating that you carefully and accurately completed them, whether or not that is actually the case.
For example, the fine print on Unum’s claim paperwork lists the fraud notice(s) relevant to your policy then states that, by signing the form, you “have read and understand the fraud notices”; “the above statements are true and complete to the best of [your] knowledge and belief”; and “[you] acknowledge that should [your] claim be overpaid for any reason it is [your] obligation to repay any such overpayment.”
At the very least, if you need to correct a mistake on prior paperwork it undermines your credibility, draws more attention to your claim, and can make it more likely that the insurer will take additional investigative action, such as in-person surveillance. Accordingly, you should always double-check everything submitted in connection with your claim to ensure it is accurate.
These are just a few tips related to completing forms, and each claim is different and involves different facts and different considerations. Remember, insurers often use ambiguity to wrongfully deny claims; however, at the same time, providing too much information, inaccurate information, and/or answers that are not well thought-out can also prejudice your ability to collect without a lawsuit. Even if you are right, and ultimately win, litigation is costly and protracted litigation can leave you financially vulnerable.
Consequently, it is much better to carefully complete the claim forms correctly from the beginning and submit your claim properly from the outset. If you do not understand your policy or have experience with how Unum handles claims, it can be difficult to sift through the forms and identify what you should/should not say. It is advisable to at least consult with an experienced disability attorney before filing your claim, so that you have an understanding of what to expect when you file and can identify any issues you need to specifically address relating to your claim.
6. When does Unum’s disability claim investigation begin?
Unum will begin investigating your disability claim the moment you make them aware of your intent to file a claim.
Typically, this is when they receive your initial proof of loss packet. But it could be earlier if you call in to request the claim packet, or mention your intent to file a disability claim to one of Unum’s employees or the agent who sold you the Unum policies.
If you are planning on calling Unum to request a claim packet without an attorney, you will likely be asked questions on a recorded line that can forever affect your ability to collect disability benefits. Unum’s policy provisions, many of which can seem innocuous, actually can be used to limit, deny or terminate a claim. Some questions may include:
- What are your symptoms, and when did they start?
- Describe all treatments/medications you’ve tried?
- How many doctors have you seen? What is their contact information?
- What are your job duties, including your duties as a practice owner, and what percentage of time do you spend on each duty?
- How much time have you taken off work? When do you plan on going back? Can you go back to work part-time or with accommodations?
- What does a typical day look like for you?
- Once you stop practicing, are you going to work somewhere else?
- When did you last work, and why did you decide to file your claim now?
- What is your income? Have you had a loss in income? Are you filing a total or partial disability claim?
7. What should I expect after filing a Unum disability claim?
After the initial proof of loss packet is submitted, Unum will assign your claim to a benefit specialist, and he or she will send you a list of the additional information needed to evaluate your particular claim.
Ongoing Proof of Loss. As the claim progresses, the company will require ongoing proof of loss and additional paperwork to be completed by you and your doctor(s). The paperwork will include questions relevant to various policy provisions that may limit your coverage, so it is advisable to be represented by an attorney.
Records Requests. After you submit the initial claim documents, Unum will likely send a follow-up letter requesting additional records and documents. For physicians, this usually includes financial documents (such as tax returns), CPT codes, profit and loss statements, employment agreements, and practice sale documents, among other things. Whether these requests are appropriate depends on the terms of your policy and nature of your claim, and should be reviewed by an attorney.
Interviews. In addition to periodic phone interviews, Unum may hire a field examiner to interview you in-person. This interview typically takes place at your attorney’s office, or at your home if you are not represented by an attorney, and interviewers/investigators may arrive unannounced if you are not represented. Unum may also seek to interview your former co-workers and/or employers about your prior job duties, and may seek to interview your friends or family members about the impact your condition has had on your day-to-day life. Whether these types of interviews are appropriate depends on the particular issues at play in your claim.
Disability Examinations. Almost every disability policy contains a provision that allows the company to have you examined as part of the claims investigation. However, different policies allow for different types of examinations. Unum’s older policies typically only expressly allow for “physical” or “medical” examinations, while newer policies typically provide for a host of different types of exams, including mental exams, vocational evaluations, rehabilitation evaluations, functional capacity evaluations, and/or neuropsychological testing, in addition to physical exams. Whether an exam is appropriate depends on the particular facts of your case, and the underlying policy language.
Disability-Related Surveillance. Unum is a company that conducts surveillance, including online and in-person surveillance. Unum generally begins by reviewing your online presence/social media and commissioning a comprehensive background check, and then moves on to in-person surveillance if they feel that is warranted. In-person surveillance can pose a particular challenge for specialty-specific physician claims, as oftentimes a physician’s symptoms and limitations may be nuanced and/or significantly alleviated once he or she steps away from the demands of practicing.
Peer to Peer Calls. When you file your disability claim, Unum will typically assign your claim to an in-house doctor and pay that doctor to review your medical records and look for any gaps or inconsistencies. Often, Unum will then direct their doctor to call your treating doctors in what is called a “peer to peer” call. Unum may tell you this is going to happen, but in most cases this takes place behind the scenes without your knowledge. In these calls, Unum’s doctors ask questions that are crafted to elicit responses that the company can use to deny or terminate your claim. For instance, Unum’s doctor might ask whether there are alternative treatment options, when your doctor thinks that you will be able to go back to work, etc. After the call, Unum’s doctor generally sends your doctor a written summary of their discussion. These summaries may contain statements that are inaccurate and prejudicial to your claim, but your doctor may be too busy to notice and may simply sign off on it without much thought, inadvertently hurting your claim. The best way to prevent this from happening is to have all correspondence with your medical providers be in writing and go through a disability attorney.
This process can feel very invasive and, if you have never experienced it before, it can be hard to tell whether your insurer is taking things too far. If you feel Unum is being too aggressive, an experienced disability insurance attorney can help you to assess the scope of the investigation and advise whether Unum has engaged in any improper conduct.
8. How and when should I approach my treating doctor about my disability claim?
Your treating physician’s support can often be critical to getting your claim approved. A hurried, uninterested doctor may not have time to devote to your claim, and Unum is a company that targets disability claims with sporadic or insufficient medical documentation. So you will need to find a treating doctor who is willing to take the time to understand how your policy works, complete claim paperwork and potentially rebut Unum’s doctors, if you are filing a Unum claim.
If you have a rare or complex condition, it is also important to receive treatment from the proper specialists and make them aware of your disability claim. Depending on your situation, your primary care doctor may be able to complete some of the paperwork. However, you will need specialists available to field more complicated questions if Unum’s doctors disagree with your reported restrictions and limitations.
When the time comes to speak to your treating physician about your claim, it is also important that your doctor understands the definition of “disability” under your insurance policy—particularly if you have an “own occupation” claim where disability is defined as the inability to practice medicine/your specialty (even if you can work in another capacity).
9. Do I need to hire a Unum disability attorney to file my claim?
While there are certainly claims that may not require attorney involvement—for example, a disability claim due to the loss of a limb or something very serious, such as paralysis—in our experience many physician claims are not that straightforward.
Many of our clients have slowly progressive conditions, conditions that may/may not respond to future treatment, or conditions that are irregularly and unpredictably debilitating, such as musculoskeletal conditions due to degenerative disc disease, Parkinson’s Disease, MS, Cystic Fibrosis, POTS, or seizures/migraines caused by periodic intracranial hemorrhages.
Other clients have conditions like a tremor, that may not prevent them from working in other jobs, but have a significant impact on their ability to work as a physician. Others have mental health conditions (anxiety disorder, panic attacks, PTSD) that cannot be verified by a single, definitive objective test.
These sorts of nuanced claims receive heightened scrutiny, including early and proactive involvement by a senior claims analyst, and direct and continued involvement of vocational/medical professionals with a return to work focus (often for the duration of the claim).
Obviously, if your claim is denied or you have a dispute over policy interpretation, you may need an attorney to become involved to resolve the matter. That being said, lawsuits with insurance companies are often costly, stressful, and, in some instances, can drag out over several years. Even if you prevail it can be an exhausting process.
In our view, it is more prudent to approach your claim carefully from the outset and have your attorney address any concerns that the insurer may have over the course of the investigation itself, so that you are not placed in a position where benefits have been cut off and your only option is a lawsuit.
In our experience, the most common areas where complexities can arise in physician claims include:
- The timing of the claim (particularly in situations where a disabling condition is slowly progressive);
- Claims made by physicians with multiple sources of income, some of which may continue post-disability;
- Claims where the underlying condition is a diagnosis by exclusion;
- Claims involving multiple co-morbid conditions;
- Claims involving recommendations for or against surgery; and
- Claims involving mental health conditions.
10. When should I contact an attorney about my claim?
Physicians who are considering filing a claim for disability insurance benefits should meet with a disability attorney well before submitting a claim. Each disability policy has different, complex language that insurance companies may manipulate to circumscribe and restrict coverage. Before filing, physicians should make a coordinated effort, with an attorney’s assistance, to determine whether their particular claim is covered, and if so, how that claim is best presented to ensure payment.
Unum Claim Tips and Answers to Other Common Unum Questions
11. Is Unum a good company?
Unum has a history of bad-faith claims practices and was hit with millions of dollars in sanctions in the early 2000’s for engaging in bad faith conduct. These practices were exposed by whistleblowers and investigative journalists, which prompted an unprecedented multi-state market conduct exam of Unum.
Unum no longer sells individual policies and currently only sells disability policies to employers.
In our experience, Unum remains one of the most aggressive companies when it comes to administering and litigating disability claims. Unum is the disability insurance company that our attorneys are seeing sued the most lately, which is not surprising, since this is a closed block of business and Unum only makes money if premiums keep coming in, and benefits are not paid out.
12. Will Unum pay me my disability benefits? Will Unum treat me fairly?
In the early 2000’s, Unum was investigated by insurance commissioners in virtually every state. This investigation included a randomized review of Unum’s prior disability claim determinations and revealed that Unum had been engaging in numerous, widespread, intentional bad-faith tactics, including:
- Improperly designating total disability claims as partial disability claims, to reduce or avoid payment;
- Refusing to acknowledge policyholder’s medical specialties, even in situations where the policies were specialty-specific;
- Withholding relevant information from medical consultants, failing to review all available medical information, and/or cherry-picking statements in medical records to deny claims without acknowledging statements that supported coverage;
- Hiring known biased consultants to conduct paper-only reviews to support claim denials, while ignoring the opinions of treating physicians that supported a finding of disability; and
- Failing to have an independent examiner evaluate claimants in-person, despite obvious and direct conflict between Unum’s consultants and the claimants’ treatment providers.
These sorts of tactics obviously make it much harder to collect, drag out the claims process, and can result in delayed or denied disability benefits. Unfortunately, we are still seeing these same types of issues with Unum on claims we are handling (or reviewing for possible representation).
Typically, Unum uses these tactics in situations where the claimant/policyholder is unrepresented and there is a lower risk of them being discovered/held accountable. We also see them in cases where the claimant has already made mistakes with the presentation/timing of their claim and Unum determines they can be more aggressive because the physician’s claim is already in a gray area.
13. I have an older Unum policy, is that better than new disability policies?
Most Unum policies are older and less detailed than the disability insurance policies being issued to physicians today. In some respects, this is a positive, as there are less express contractual obligations that must be met to collect. Additionally, in most states, if an insurance contract is vague, it is construed against the insurance company as the drafter of the contract.
That being said, Unum is a company that is often inclined to litigate disputes over vague policy terms and take them as far as possible, in an effort to deplete your resources and wear you down. Even if you have the law on your side, lawsuits can still drag out for years—particularly if a claim has not been well-presented and Unum has been left to its own devices and allowed to generate a one-sided claim file that only focuses on information that supports denial or reduction of benefits.
14. How long will it take Unum make a claim decision?
As noted above, Unum no longer sells individual policies and Unum’s brand already took a major hit after the multi-state market exam. As a result, they no longer have an incentive to provide prompt payment/good customer service and, for the most part, Unum claim investigations are very thorough and time consuming.
As with other disability claims, the length and difficulty of the process depends on the amount of money on the line and the specific issues at play. In heavily contested Unum claims, it has taken our office over a year to secure benefits, even in cases that do not require litigation.
Unum is also the disability insurance company we are seeing being sued the most frequently. If your claim reaches the point where it has been denied and litigation is necessary, Unum typically draws out that process for as long as possible, including spending the additional time and expense to appeal lower court decisions.
The best way to speed up the process and keep your Unum claim on track is to present it properly from the beginning. If you make any mistakes or fail to provide important information, Unum tends to use that as an opportunity to delay or deny payment.
15. I heard Unum conducts surveillance. I have an own-occupation policy, so why does Unum care what I do day-to-day?
Most disability insurance companies conduct surveillance on long-term/permanent disability claims, and Unum is no exception.
Unum’s surveillance initially focuses on online presence, and in a high dollar case Unum will typically commission a full-scale background check that returns a report that is several hundreds of pages long. These reports evaluate past jobs, residences, and contacts, and now will often include printouts of social media pages—including social media pages of friends and family that they think might post photos of you (even if your own social media is set to private).
If this initial search reveals that you have an active lifestyle, Unum may hire in-person private investigators to follow you and attempt to gain footage of you doing something that is arguably inconsistent with your reported limitations.
Unum then looks through claim forms and medical records to cherry-pick statements about you being active, and then attempts to piece all of these things together to argue that your condition has improved. Even if you are not actually working, Unum will look to your daily activities to try and argue that you have the capacity go back to work.
For example, in one case, Unum determined that an insured was able to go back to work as a trial attorney because he was able to wear his seatbelt and help his wife around the house with chores. While it may seem ridiculous that such simple tasks can be equated with the demands of a trial attorney, it is a tactic we see Unum try all too often and it highlights the importance of having an attorney represent you from the outset.
16. Why isn’t Unum recognizing my specialty?
Some of Unum’s policies indicate that a physician’s occupation will be considered to be his or her specialty, as long as it’s recognized by the ADA. For example, if you are a practicing surgical anesthesiologist with a specialty-specific policy, Unum should be considering the specific duties associated with practicing surgical anesthesiology, not general practice.
On its face, this is good coverage and a good policy provision to have. However, most of Unum’s specialty-specific policies are part of its old block of business that it oversold (and regrets selling). Consequently, in practice, it can be difficult to get Unum to recognize a physician’s specialty as his or her occupation.
Unum will often start out a physician claim by referring to you broadly as a “physician” or “medical doctor” in early correspondence commenting on their understanding of your occupation. If there is no initial pushback, Unum will remain “willfully ignorant” of your specialty and evaluate your claim as if you were an internist, and not a specialist.
Unum may also seek to classify such claims as partial disability claims instead of total disability claims. For example, in one case, Unum determined a surgeon was not totally disabled because he had performed some in-office procedures and just one major surgery after his claimed date of disability.
Consequently, if you are a specialist with a specialty-specific policy, it is important to be very precise and proactive when presenting your disability claim, and not make any changes to your job duties without first consulting with an experienced disability attorney.
17. Why isn’t Unum listening to my doctor? Why is Unum ignoring what is in my medical records?
We’ve been involved in several cases where Unum cherry-picks statements from medical records that (purportedly) support a claim denial, while ignoring statements that are support a determination of total disability. Recent case filings and lawsuits filed against Unum also reflect that this is an ongoing problem.
In one such case, Unum actually had medical records belonging to someone else in the file; yet, instead of noticing their error and requesting correct records, they simply denied the claim.
In another recent case, Unum cherry-picked from records regarding surgery—honing in on statements that the insured had had surgery and had shown some improvement. However, Unum ignored statements in the records that indicated the insured was not yet able to return to work.
This “head in the sand” approach is a common Unum tactic, and must be countered by proactively providing medical documentation that proves up your condition in no uncertain terms. Otherwise, Unum is very adept at crafting one-sided claim files and pushing claims into litigation, in the hopes that the long, drawn-out process will wear you down and you will either go away or accept a low-ball settlement.
18. Does Unum hire biased doctors to help them deny claims?
Unum has several doctors at its disposal that regularly sign off on claim denials. However, it is not enough for you to claim the doctor is biased. If you don’t have anything to back it up, Unum (and most courts) will just ignore you.
In order to show bias, you need to be able to show a pattern of making similar comments, finding in Unum’s favor, only working with insurance companies, being criticized by other courts for being biased, etc. Unum is not averse to using doctors with such pedigrees, so it is often possible to do this in Unum claims; however, it does take quite a bit of time and effort to collect this information and argue/establish bias.
19. Unum’s letter says it is conducting a “sickness versus injury” evaluation. What is that, and why does it matter?
Many older Unum policies provide different benefits for disabilities caused by injury, as opposed to disabilities caused by sickness. Most newer disability policies do away with this distinction, but if you have a Unum policy, your eligibility for certain benefits, such as lifetime benefits, may hinge upon whether you became disabled from injury or sickness.
In some instances, this is a straightforward analysis. In others, it is not as straightforward and can give rise to lawsuit.
For example, if you are a surgeon and injure your back, resulting in radiculopathy that prevents you from performing surgeries, you probably expect that you will receive benefits under the injury provision. However, if your medical records show prior issues with your spine, or you even have a history of seeing a chiropractor, Unum will most likely argue that you had degenerative disc disease, this made you predisposed to the injury, DDD is a sickness, and it came before the injury so your disability claim is due to sickness, no injury.
Another common scenario is a disability claim involving multiple conditions, with a mixture of sickness and injury limitations. Depending on the wording of the policy, you may have to show that the injury would have been independently disabling to establish that your disability is due to injury (and not due to other causes).
20. What is ERISA? Why is Unum saying my policy is covered by ERISA?
ERISA is a federal statute that takes away certain state law remedies, such as trial by jury or bad faith/punitive damages. It also creates a deferential standard of review that favors insurers. As a result, it is typically more difficult to challenge disability denials under ERISA than it is under state law.
Unum is aware of this, and even circulated an infamous memo several years ago identifying ERISA as an opportunity to reduce claim payouts and save money. Public disclosure of this memo and subsequent lawsuits have not deterred Unum from seeking to apply ERISA to individual disability claims—particularly policies sold in the early 1990’s.
This area is a complicated legal arena, but the general concept is that employer-plans are subject to ERISA, while individual policies purchased privately are not. However, there is a gray area if an individual policy has ties to your employer or others who purchased policies at the same time, or it is unclear how the premiums were collected and paid.
In the early 1990’s, Unum often marketed to entire offices and had various programs that allowed employers to collect premiums and/or offered discounts to groups of individuals purchasing policies at the same time. Courts are split on whether these sorts of programs are enough to subject an individual policy to ERISA, and this is an area where Unum continues to argue its positions in the hopes that it will convince appellate courts to reverse lower court holdings against Unum on this issue.
In short, this is an arena that involves complex legal doctrines and multi-factor tests that can be utilized by Unum to draw out litigation, even if Unum ultimately has a losing argument. If Unum is claiming that your individual policy that you purchased yourself is governed by ERISA, this is a red flag and you should speak with an experienced attorney as soon as possible.
The information provided above is offered purely for informational purposes. It is not intended to create or promote an attorney-client relationship, and does not constitute and should not be relied upon as legal advice.
Every claim is unique and the discussion above is only a limited summary of information that may be relevant to your claim. If you are concerned that Unum is not handling your claim fairly, an experienced disability insurance attorney can help you assess the situation and determine what options are available to you.
Notable Unum Disability Insurance Cases
Himes v. Provident Life & Accident Ins. Co., No. 3:19-CV-00215 (M.D. Tenn. Jan. 28, 2020), report and recommendation adopted sub nom. Himes v. Provident Life & Accident Insurance Co., No. 3:19-CV-00215 (M.D. Tenn. Mar. 3, 2020).