A Western District of New York State federal held that Unum Life Insurance Company of America (“Unum”) decision to deny a Senior Bank Vice President’s disability benefits was not based on substantial evidence. Consequently, the court remanded the case back to Unum for another review of the medical evidence.
The Policy Language
According to HSBC Bank USA’s short-term disability plan, Strope was eligible for benefits for up to 26 weeks if she was “continuously disabled” through the policy’s elimination period. Disability is defined as being “limited from performing the material and substantial duties of your regular occupation” due to sickness or injury and incurring a “20% or more loss in weekly earnings” due to the same sickness or injury.
Strope’s Disability Claim
At the time of disability, Strope worked as a Senior Bank Vice President for HSBC Bank USA. Strope saw her doctor for complaints of extreme fatigue in April 2005, who recommended she remain out of work until her next appointment the following month. Strope applied for short-term disability (“STD”) benefits and submitted office notes, attending physician statements, and support letters authored by her doctors. Strope was eventually diagnosed with chronic fatigue syndrome, depression, hypothyroid, borderline sleep apnea and possible Lupus Erythematosis. Ms. Storpe’s symptoms included extreme fatigue, joint pain of the knees, hips, feet, hands, and upper back that were tender upon palpitation, difficulty concentrating, and trouble ambulating. Unum denied Ms. Strope’s STD claim, based on a review by a nurse-consultant, and she appealed that decision. With her appeal, Ms. Strope included additional medical records and laboratory results. Unum denied Ms. Strope’s STD appeal, based on a review by a nurse-consultant.
Ms. Strope also applied for long-term disability (“LTD”) benefits, which were initially denied by Unum but later approved.
The Court’s Decision
The court ruled that Unum’s decision was not based on “substantial evidence” when it “flatly rejected the opinion of plaintiff’s treating physician, yet never requested an independent medical examination.” The court further noted that Unum’s denial was not based on evidence that Strope could work, but on what Unum perceived as a lack of clinical evidence supporting disability. As a result, the court remanded—or sent back—Strope’s disability claim back to Unum for a full and fair review, allowing Strope to submit additional evidence supporting her disability claim.
As can be seen by the outcome of Strope’s disability lawsuit, these cases can be complicated. Having an experienced disability insurance attorney on your side is crucial to your case.
Disability Insurance Companies Have Lawyers. Shouldn’t You?
Because this law firm was created to focus on disability insurance, we have developed an expertise in this complex area of the law.
Our expertise in long-term disability claims means our clients have the backing of a law firm that has attorneys who:
- are experts in disability claims;
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All our lawyers commit every day of their legal career to helping people get disability benefits from UNUM, MetLife, Prudential, Northwestern Mutual, Hartford, CIGNA, and others.
Because federal law applies to most disability insurance claims, we do not have to be located in your state to help. We represent clients nationwide.
Call to get experienced disability lawyers on your side with:
- Submitting a disability insurance claim;
- Appealing a long-term disability denial;
- Negotiating a lump-sum settlement; and/or
- Filing a lawsuit against your disability insurance company.
Call (800) 969-0488 to request your free consultation with an experienced disability attorney. Pay no fees or costs unless you get paid.
