A federal court in Kansas awarded long-term disability benefits to an individual who suffered a stroke, finding Unum’s denial of benefits based on a pre-existing condition exclusion was wrong. The court held that Unum abused its discretion in denying Mr. Meyer’s disability claim.
Mr. Meyer was hired by Niska Gas Storage on October 15, 2008. Through his employment, Mr. Meyer became eligible for long-term disability coverage on November 14, 2008. On March 10, 2010, Mr. Meyer suffered a stroke causing permanent damage. No longer able to work, Mr. Meyer filed a claim with Unum for long-term disability benefits.
Unum’s long-term disability policy contained a pre-existing condition exclusion. The exclusion stated that benefits would not be paid for any disabilities caused by, contributed to by, or resulting from a pre-existing condition. Under the policy, an individual had a pre-existing condition if:
- You received medical treatment, consultation, care or services including diagnostic measures, or took prescribed drugs in the 6 months prior to the effective date of coverage; and
- The disability begins within the first 24 months after the effective date of coverage.
The important question in this case was:
Did Mr. Meyer receive treatment, consultation, care or services, or took prescribed medications for a condition that caused, contributed to, or resulted in his disability during the 6 months before he became covered?
Unum argued he did. It claimed that during the 6 month lookback period, Mr. Meyer became treated and took medications for atrial fibrillation and high blood pressure. Unum stated that these conditions caused, contributed to, or resulted in the disabling condition. Thus, Unum denied Mr. Meyer’s long-term disability benefits.
Mr. Meyer appealed Unum’s decision and argued that these pre-existing conditions are not the cause of his disability. Unum denied Mr. Meyer’s appeal relying exclusively on a medical record review completed by one of Unum’s doctors. Mr. Meyer filed a lawsuit against Unum in federal court.
The Court’s Review of Mr. Meyer’s Claim
The court performed a comprehensive review of Mr. Meyer’s claim and held Unum was wrong to deny his benefits. The court ultimately found Unum abused its discretion in denying Mr. Meyer’s claim based on its finding that his disability was caused by or contributed to by pre-existing atrial fibrillation and hypertension.
The court identified three reasons as to why Unum’s decision was wrong:
- Unum’s in-house doctor’s opinion was not consistent with the medical records;
- Unum adopted its in-house doctor’s opinion without conducting an independent examination; and
- Unum misinterpreted the long-term disability policy’s definition of a pre-existing condition
The court dismissed Unum’s in-house doctor’s opinion. It found that the medical evidence did not show that Mr. Meyer’s pre-existing conditions caused his stroke. The court also found Unum unreasonable in relying exclusively on its in-house doctor’s opinion while dismissing all other evidence. It held that Unum could have and should have sent Mr. Meyer to a medical evaluation given this disagreement.
Importantly, the court ruled Unum ignored the policy definition of pre-existing condition. Under the policy, Mr. Meyer was entitled to benefits if he was limited from working unless he had a pre-existing condition which caused, contributed, or resulted in his disability. The court found the stroke caused, contributed to, or resulted in Mr. Meyer’s disability, not atrial fibrillation and hypertension.
The court ruled in Mr. Meyer’s favor and awarded his long-term disability benefits.
Disability Insurance Companies Have Lawyers. Shouldn’t You?
If you are facing a long term disability claim denial based on a pre-existing condition exclusion, you should consult an experienced disability lawyer. Our lawyers specialize in disability claims with insurance companies.
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