UNUM Denial Reversed: UNUM Failed In Its Duty to Request Additional Testing
Chris Bunger. worked as a web content specialist for Costco. He became unable to work after he began suffering from anxiety, lightheadedness, vertigo, and Raynaud’s phenomenon, chronic fatigue syndrome and brain fog. He was later also diagnosed with Lyme disease. He filed claims for disability benefits under Costco’s Short Term Disability (STD) and Long Term Disability (LTD) benefit plans, and was initially approved by the plans’ insurer, UNUM Life Insurance Company.
UNUM Terminates LTD Benefits
Mr. Bunger received disability benefits until Unum ultimately denied him benefits because “Mr. Bunger ha[d] no properly diagnosed conditions, and ha[d] not shown that he is unable to perform his job functions.” Mr. Bunger appealed this decision, arguing that he is totally disabled under both the short and long terms plans due to “chronic fatigue syndrome, Lyme disease, or an unspecified illness which causes extreme fatigue and an inability to concentrate.”
Mr. Bunger had initially been approved for STD benefits. Under Costco’s Unum policy, an employee is entitled to short-term disability benefits if they are “limited from performing the material and substantial duties of [his] own job … due to … sickness or injury; and [he] ha[s] a 20% or more loss in weekly earnings.” These short-term disability benefits are only available for a 26-week period.
After this 26-week period passed, long-term benefits were available under the Unum groupd disability insurance policy which funds the Costco LTD plan. The Long Term Disability plan has differing definitions for disabled based on how long the person has been deemed disabled. The LTD Plan terms state that “for the first nine months of long-term disability coverage, ‘disabled’ is defined in the same way for [long-term disability] benefits as it is for [short-term disability benefits. . . . However, after about nine months, an employee must show that he is disabled from ‘any gainful occupation’ as opposed to just his ‘own job.’” UNUM decided that Mr. Bunger no longer met this definition, and terminated his benefits.
UNUM Mishandled the Appeal
Mr. Bunger appealed UNUM’s termination of his LTD benefits. Throughout the appeal process, Unum requested additional medical documentation regarding Mr. Bunger’s medical conditions. Mr. Bunger continuously visited his primary care doctor who continued to diagnose him with the same symptoms. The doctor opined that Mr. Bunger would be unable to work for one year, but she would continue to study his symptoms. However, she never emphasized the need additional testing to ensure that the initial diagnoses for Lyme disease was correct; she also never told Mr. Bunger to see a specialist for Lyme disease.
Mr. Bunger supplied Unum with the medical records from his primary care doctor. Unum noted internally that they were concerned with the medical treatment that he was receiving because Unum thought that Mr. Bunger’s primary care doctor should have referred Mr. Bunger to “several specialists, including an infectious disease specialist, a rheumatologist, and a behavioral health specialist.” Unum’s medical reviewers talked to Mr. Bunger’s primary care doctor to discuss her medical opinion. UNUM never brought up its view of the need for other testing or treatment, yet it ultimately denied Mr. Bunger’s appeal. UNUM’s decision letter stated the reason for denying the claim was that its medical reviewer felt that Mr. Bunger was not receiving the appropriate medical treatment for his symptoms and, therefore, his conditions were not adequately controlled, affecting his “functioning.”
Federal Court Reverses UNUM Because It Failed to Tell the Claimant About the Testing or Treatment It Thought Was Needed
After Unum denied Mr. Bunger’s appeal, Mr. Bunger brought sued UNUM in a Washington federal court under ERISA, the federal law that governs employer sponsored disability plans. The District Court in Washington did not rule that Bunger was entitled to LTD benefits. However, the court ruled in his favor, reversing UNUM.
The court’s opinion explained that Unum cannot deny benefits to someone on the basis of testing or treatment they did not obtain, without requesting that they obtain the additional testing, diagnostics or opinions from medical specialists. If UNUM thought these tests or medical care were needed in order to make an informed decision, it cannot make an UNinformed decision without that information. The court ordered Unum to review Mr. Bunger’s appeal again with emphasis on asking Mr. Bunger to see medical specialists to potentially support his primary care doctor’s initial diagnoses.
Takeaway – UNUM Was Not Allowed to Stick Its Head in the Sand; It Had to Ask for Testing
If a disability insurance company like UNUM feels the need that additional labs or medical records from medical specialists are needed, then the insurance company must ask the employee claimant to provide such information before denying benefits. Therefore, a disability insurer may not deny benefits if it takes the position that other information is needed because the medical records are insufficient to support a finding of disabled based on the policy definitions of being disabled.
CASE: Bunger v. Unum Life Insurance Company, No. 2:15-CV-01050-RAJ, 2016 WL 3912986 (W.D.Wa. 07/20/2016).