One is never safe from a claim termination! All it takes is a new adjustor or new head of the disability department, or someone else with authority who is intent on denying claims and increasing company profits. And sometimes it can even be the result of an offhand comment in medical records. In Pellegrino v. First Unum Life Ins. Co. (1:20-CV-484 (N.D.N.Y. Aug. 31, 2021)), Unum paid a claim involving medical conditions which never improve for over five years before terminating it.
Mr. Pellegrino was a network engineer, a light demand occupation. While doing some air conditioning work around his house in September 2012, he threw his back out. He experienced severe pain and could no longer perform his occupation. He filed a claim through his workplace for short-term disability. Unum eventually paid that claim through its end date in March 2013. When the long-term disability claim matured, Unum paid it too but did so under a reservation of rights, contending that it had not made a final decision.
An Unum field representative visited Mr. Pellegrino's house and noted that he did not appear to be in pain while he sat for a two-hour and 15-minute interview. Unum sent the file to its in-house doctors, who thought there were restriction and limitation gaps in the record as the claimant was not under the regular care of a physician. The treating doctor had noted that Mr. Pellegrino needed a spinal fusion and could not work, but that was not enough. Unum sent some records and Mr. Pellegrino to an independent medical examiner. That examiner saod Mr. Pellegrino could perform some sedentary work but not light physical demand work.
Unum continued to pay the claim for about 5 years — through March 2018. Unum requested a second medical examination by a different physician. He determined that Mr. Pellegrino had the functional capacity to lift, carry, push and pull up to 20 pounds, and could occasionally walk, stand, stoop and frequently sit. Thus, he was capable of light physical demand work on a full-time basis, despite not having worked since 2012. Unum wasted no time terminating the claim in April 2018, contending that Mr. Pellegrino was no longer disabled and was fit to return to his own occupation.
Mr. Pellegrino appealed the termination of his benefit. Unum refused to reverse the decision and buttressed it with additional evidence. Mr. Pellegrino filed suit. The court heard the case and determined that under the arbitrary and capricious standard, Unum's decision did not have to be correct but merely supported by substantial evidence. The doctor's evaluation gave Unum a reasonable basis for its decision notwithstanding the fact that the treating physician felt differently.
No long-term disability ERISA claimant is ever safe with an insurer such as Unum. If someone is represented on back benefits only, what happens after they are on claim and the claim is terminated? It may be difficult to secure legal counsel on a contingent fee basis with only a few months' benefits at stake. The necessary evidence and appeal must be gathered and presented in short order. Claimants need a disability lawyer who will be with them for the long haul.