Los Angeles and Orange County Disability Insurance and ERISA Claim Attorneys Fight Unum Claim Denials

At McKennon Law Group PC, we aggressively exhaust all avenues to pursue your right to receive benefits from life and disability insurers like Unum, in part, because we know insurers like Unum.  McKennon Law Group PC’s founder, Robert J. McKennon, represented Unum and other such insurance companies in the past, which is part of the reason why we are to settle so many claims prior to litigation.

Unum is a Fortune 500 company.  Although Unum is the largest group and individual disability carrier in the United States, Unum also provides a wide array of insurance coverage, including disability, accident, critical illness and life insurance.  Unum offers insurance products through several companies:

• Colonial Life & Accident Insurance Company;
• First Unum Life Insurance Company;
• Provident Life & Accident Insurance Company;
• Starmount Life Insurance Company;
• The Paul Revere Life Insurance Company; and
• Unum Insurance Company.

Unum’s Settlement Agreement with the California Department of Insurance

In 2004, the then New York State Attorney General Eliot Spitzer, New York State Insurance Superintendent Gregory Serio, and lead regulators of Maine, Massachusetts and Tennessee announced a settlement with UnumProvident and five of its subsidiaries.

The settlement resolved issues surrounding Unum claims practices criticized by 60 Minutes and NBC Dateline. Investigations were conducted by the three lead regulators, as well as the United States Department of Labor. According to Attorney General Spitzer, “This settlement sends a strong message to disability insurance companies that improper denials of disability claims will not be tolerated.”

The actual conduct market examination identified several claims handling practices of concern to lead regulators, including:

• Excessive reliance on in-house medical staff to support the denial, termination or reduction of benefits;
• Unfair evaluation and interpretation attending physician or independent medical examiner reports;
• Failure to evaluate the totality of the claimant’s medical condition; and
• Placing an inappropriate burden on claimants to justify eligibility for benefits.

Regulators also announced that the Unum companies would pay a fine of $15 million and reassess 200,000 claims.  If the companies failed to meet the terms of the Plan of Corrective Action set forth in the Regulatory Settlement Agreement (“RSA”), a substantial fine of $145 million would be imposed.  In addition to the $15 million fine and reassessment of 200,000 claims, the Unum companies were also required to:

• Restructure their claim handling procedures to ensure that all future claims are reviewed in a fair and objective manner;
• Select medical examiners based solely on merit, and ensure that those examiners review all relevant records before reaching a determination;
• Require personnel making impairment determination to certify that their decisions were based upon a review of all the relevant evidence;
• Prohibit company personnel from trying to influence the outcome of disability claim appeals;
• Grant significant weight to findings of disability by the United States Social Security Administration;
• Improve employee training;
• Create a new Regulatory Compliance Unit to monitor the companies’ compliance with applicable laws and regulations;
• Conduct periodic audits of the new claim reassessment process, to ensure compliance with the terms of the settlement; and
• Appoint three new independent members to the Board of Directors, add one new independent member to the Audit Committee and create a new Regulatory Compliance Committee of the Board of Directors.

Also, Section B.3c(i) of the RSA was amended to include this provision to assist claimants:

Giving significant weight to an attending physician’s (“AP”) opinion, if the AP is properly licensed and the claimed medical condition falls within the AP’s customary area of practice, unless the AP’s opinion is not well supported by medically acceptable clinical or diagnostic standards and is inconsistent with other substantial evidence in the record.  In order for an AP’s opinion to be rejected, the claim file must include specific reasons why the opinion is not well supported by medically acceptable clinical or diagnostic standards and is inconsistent with other substantial evidence in the record. (Effective October 3, 2005)

In 2005, Unum and all of its subsidiaries (including Colonial, First, Provident, Starmount and Paul Revere) entered into a settlement agreement with the California Department of Insurance (“CDI”) after an investigation into the subsidiaries’ claims handling practices.  As a result, Unum agreed to change its practices and policies to conform with California law.  Unum also paid an $8 million fine and changed several policy provisions, including the definition of “total disability” in its disability policies.

In the California Settlement Agreement, Unum agreed to:

Give significant weight to an attending physician’s opinion, if the attending physician is properly licensed and the claimed medical condition falls within the attending physician’s customary area of practice, unless the attending physician’s opinion is not well supported by medically acceptable clinical or diagnostic standards and is inconsistent with other substantial evidence in the record.  In order for an attending physician’s opinion to be rejected, the claim file must include specific reasons why the opinion is not well supported by medically acceptable clinical or diagnostic standards and is inconsistent with other substantial evidence in the record.

How does Unum Deny Life and Disability Insurance Claims?

Unum denies claims based on many reasons including, but not limited to, the following:

• The medical evidence does not support the life or disability claim
• The claimant did not provide adequate medical support for the life or disability claim
• The claimant did not provide documentation or proof of loss evidence in a timely manner
• The medical condition which is the subject of the claim is a pre-existing condition
• The insurance application contained materially false information, and thus the policy can be rescinded
• Surveillance of the claimant suggests that the claimant is not totally disabled
• The claimant’s policy has lapsed for failure to pay premiums
• An exclusion in the life or disability policy precludes coverage for the claim

What Should Disability or Life Insurance Claimants Look for When Unum Denies a Claim?

• Improperly investigating the claim
• Improperly obtaining opinions from unqualified persons/supposed experts
• Improperly misreading or misinterpreting medical records
• Improperly hiring and using biased “independent” medical reviewers and examiners
• Improperly denying a claim without any medical examination
• Improperly refusing to acknowledge subjective disabling conditions such as mental disorders, autoimmune disorders, fibromyalgia, and chronic fatigue syndrome because there is no objective evidence of the condition
• Improperly asserting a pre-existing condition
• Improperly attempting to rescind the policy
• Improperly denying a claim with the intent to wear the claimant down to a lower settlement
• Improperly over-relying on surveillance evidence to conclude a claimant can work
• Improperly over-relying on social media evidence to conclude a claimant can work
• Improperly failing to have a meaningful dialogue with the claimant
• Improperly failing to use findings by the Social Security Administration to support a disability claim

If you feel you have a wrongfully denied claim for disability, life or other insurance involving Unum, the McKennon Law Group PC will fight for your benefits. 

Having an aggressive and experienced disability, health and life insurance litigation attorney is the most important decision you can make for the success of your insurance claim.  If your claim for health, life, accidental death or dismemberment, short-term disability or long-term disability insurance has been wrongfully denied or suddenly terminated, fill out a free consultation form or call (949) 387-9595 to schedule a free consultation with the attorneys of the McKennon Law Group PC, several of whom previously represented insurance companies and are exceptionally experienced in handling ERISA and non-ERISA, bad faith insurance claims.