A California disability attorney recently filed a federal lawsuit on behalf of a Cardiologist who has been unable to fully perform the duties of his occupation since a bicycle accident left him with serious injuries. The Plaintiff filed this disability lawsuit to recover long-term disability benefits that were wrongfully denied by Unum.
Facts of the Case Against Unum Insurance Company
Plaintiff purchased many forms of insurance policies from Unum and its predecessor, Provident Life and Accident Insurance Company from 1987 to 1991 to cover both himself and his medical practice.
On or about August 24, 2007, Plaintiff was involved in a bicycle accident where he sustained multiple fractures, including one of his left shoulder, a hip fracture, a few rib fractures, and a fracture of the left clavicle. This occurred when the Plaintiff was 61 years of age.
The injuries prevented Plaintiff from performing his job duties as a cardiologist from August 2007 until late March 2008. Plaintiff also incurred additional overhead expenses for the salaries of his replacement staff at his clinic while being disabled.
Plaintiff was only able to work 2 hours a week from March 2008 through May 2008, but beginning in the summer of 2008, was able to work a few half-days a week.
However, Plaintiff has not been able to, and still cannot, work full-time due to his injuries.
Plaintiff has received numerous detailed evaluations and treatments, but despite all of them, he still has not totally recovered and suffers from ongoing hip and shoulder pain. This has caused Plaintiff to work only reduced hours from mid-2008 to the present. He also has experienced fatigue and weakness despite doing yoga and aerobic workouts.
Plaintiff cannot carry out his job duties as a cardiologist safely after more than a few hours. Additionally, he cannot work at the same speed and intensity as he had before the accident.
As a result, Plaintiff’s income has dropped by more than 20%.
Denial Of Unum Disability Benefits Claim
In April 2009, Unum sent a letter stating that no more benefits would be paid under the policies. This was based on a review of the CPT codes and the assumption that Plaintiff was the one who personally billed all procedures. This led Unum to believe that Plaintiff was now working full time again and had regained all of his lost income.
Additionally, no further reimbursement of replacement salary would be provided under the Substitute Expense Benefit Rider of the Business Overhead Policy that Plaintiff began in 1987.
The assumption by Unum was incorrect because the CPT codes reflected the billings of the corporation, not the Plaintiff’s personal billings or personal income. Plaintiff had always provided Unum with statements of his personal income throughout this ordeal.
Plaintiff appealed Unum’s denial on February 8, 2010, claiming he was entitled to residual disability benefits because he was only working part-time and had loss over 20% of his monthly income. Plaintiff supplied tax returns, W-2 forms, and CPT code billing data to show this.
Unum returned Plaintiff’s claim file to the Benefits Center on February 23, 2010.
On March 19, 2010, Unum recalculated Plaintiff’s financial income based on documents supplied by the Plaintiff. Unum also requested CPT reports from each provider in the Plaintiff’s office and for the Plaintiff to supply Unum with a disability status update.
On March 24, 2010, Unum requested monthly profit and loss statements from the Plaintiff, which Plaintiff submitted on April 8, 2010.
Plaintiff also supplied Unum with an Attending Physician’s Statement from his treating physician, Dr. Veliz, on April 11, 2010.
Unum requested complete unredacted copies of Plaintiff’s personal and business tax returns on April 27, 2010.
On May 27, 2010, Unum informed Plaintiff that Plaintiff’s claim would need to be considered under the Residual Disability provision of his policies, since the evidence submitted proved that he did work part-time.
Plaintiff continued to submit additional documentation regarding personal income, taxes, and disability status between June 2010 and August 2010.
On September 10, 2010, Unum informed Plaintiff that due to the Plaintiff being diagnosed with Fibromyalgia and being treated for depression, Unum’s behavioral health and general medical physicians would review Plaintiff’s records.
On September 21, 2010, Plaintiff again submits profit and loss statement for July and August 2010 as Unum requested. Plaintiff also questioned the need to send his claim to be reviewed by Unum’s behavioral health and general medical physicians.
On October 12, 2010, Unum informed Plaintiff that it was in the process of finishing its medical review.
On November 1, 2010, Plaintiff again submits profit and loss statement and the invoices for insurance for September 2010.
On November 3, 2010, Unum upheld its decision to deny long-term benefits based on the conclusion that “residual disability benefits are not payable because the medical information we have received and reviewed does not support restrictions or limitations in his ability to perform the material and substantial duties of a cardiologist.”
On January 14, 2011, Unum’s Appeals Division upheld the denial of Plaintiff’s LTD benefits.
California Disability Lawyer Files Lawsuit Against Unum
According to the lawsuit, the plaintiff alleged that Unum committed the following against the plaintiff:
- Breached the policy of insurance by refusing to pay full benefits as called for in each of the four Plans that the Plaintiff had paid for.
- Plaintiff has suffered loss of benefits and consequential damages from the failure of not receiving full benefits from each of the four Plans.
- Unum did not act fairly and in good faith toward the Plaintiff and his claims.
- Denying Disability Benefits and Residual Disability Benefits arbitrarily and without good reason or proper investigation.
- Denying Overhead Expense benefits without good reason or proper investigation.
- Acting with oppression, fraud, and malice to intentionally cause harm and harassment toward the Plaintiff.
- Plaintiff has Attorney’s fees.
- Plaintiff has emotional and mental distress.
Relief Sought By The Plaintiff In The Unum Lawsuit
Due to Unum’s actions, the plaintiff seeks the following relief from the Court:
- Benefits due under the insurance policies.
- The sum of consequential damages as provided via the proof submitted.
- Costs of bringing this lawsuit to trial.
- Attorney fees as shown via the proof submitted.
- For all accrued interest on the benefits not having been paid.
- For all other relief that the Court finds just and proper.