Fighting for Justice: Empowering Individuals Against Unjust Denials by Unum and Other Disability Insurance Companies

When individuals pay for disability insurance, they are investing in their financial security in case they become unable to work due to injury or illness. However, many policyholders find themselves in a difficult situation when disability insurance companies, such as Unum, deny their claims for benefits. Unum, one of the largest providers of disability insurance, has faced numerous lawsuits and accusations of wrongfully denying legitimate claims. This article aims to empower individuals by providing information about their rights and how to fight against unjust denials by Unum and other disability insurance companies.

Understanding Disability Insurance

Disability insurance is designed to replace a portion of an individual’s income if they are unable to work due to a disability. There are generally two types of disability insurance: short-term and long-term. Short-term disability insurance typically covers a percentage of lost income for a period of weeks to months, while long-term disability insurance may provide benefits for years or even until retirement, depending on the policy.

Many employers offer group disability insurance as part of their benefits packages, but individuals can also purchase private disability insurance policies. The specifics of coverage, including the definition of disability and the process for filing claims, vary between policies and insurance companies.

The Role of Unum and Other Disability Insurers

Unum is one of the largest providers of disability insurance in the United States, offering both individual and group policies. The company has come under scrutiny for its claims-handling practices, particularly in cases involving long-term disability. Over the years, Unum has been the subject of numerous lawsuits and regulatory actions for its denial of claims.

While Unum is a prominent example, other disability insurers also engage in practices that can result in the denial of legitimate claims. Insurers may have financial incentives to deny claims, as paying out benefits can impact their profitability. As a result, many individuals find themselves battling their insurance companies for the benefits they are rightfully owed.

Common Reasons for Denial

Disability insurance companies may deny claims for a variety of reasons. Some of the most common reasons include:

• Insufficient Medical Evidence: Insurance companies often require detailed medical documentation to support a claim of disability. If the insurance company believes the evidence provided is insufficient to prove that the individual is disabled, it may deny the claim.

• Disputed Definition of Disability: Disability insurance policies often define “disability” in specific ways. For example, a policy may distinguish between being unable to perform one’s own occupation and being unable to perform any occupation. Disputes over the definition of disability can lead to denied claims.

• Pre-Existing Conditions: Many disability insurance policies contain exclusions for pre-existing conditions. If the insurance company determines that the disability is related to a pre-existing condition, it may deny the claim.

• Policy Lapses: If a policyholder fails to keep up with premium payments, the insurance company may claim that the policy has lapsed and deny benefits.

• Surveillance and Investigation: Insurance companies may conduct surveillance or hire private investigators to monitor claimants. If the insurer believes the claimant is not as disabled as they claim, it may deny the claim based on the findings of the investigation.

Steps to Take After a Denial

If a disability insurance claim is denied, individuals do not have to accept the decision without a fight. There are several steps they can take to appeal the denial and pursue the benefits they are owed.

• Review the Denial Letter: The first step is to carefully review the denial letter from the insurance company. This letter should explain the reasons for the denial and provide information about how to appeal the decision. It is important to understand the specific grounds for the denial in order to effectively challenge it.

• Gather Additional Evidence: One of the most effective ways to strengthen an appeal is to gather additional medical evidence that supports the claim of disability. This may include updated medical records, test results, and statements from treating physicians. Providing thorough and detailed documentation is critical to overcoming a denial.

• Consult an Attorney: Disability insurance claims can be complex, and individuals may benefit from consulting an attorney who specializes in insurance law. An experienced attorney can help navigate the appeals process, communicate with the insurance company, and build a strong case for benefits.

• File an Appeal: Most disability insurance policies include an internal appeals process that allows claimants to challenge a denial. It is essential to file the appeal within the time frame specified in the policy, which is typically limited to a few months. Missing this deadline could forfeit the right to appeal.

• Consider Legal Action: If the internal appeal is unsuccessful, individuals may have the option to file a lawsuit against the insurance company. In many cases, insurance companies may settle the dispute rather than risk a costly legal battle, particularly if there is strong evidence supporting the claim.

The Role of ERISA in Disability Claims

For individuals who have disability insurance through their employer, the Employee Retirement Income Security Act (ERISA) plays a significant role in the claims process. ERISA is a federal law that governs employee benefits, including disability insurance, and provides protections for employees who have been denied benefits.

ERISA establishes procedures for appealing denied claims and filing lawsuits against insurance companies. Under ERISA, individuals must first go through the internal appeals process before they can file a lawsuit. If the case goes to court, the judge will review the administrative record, which includes all the evidence submitted during the claims and appeals process. This means it is critical to provide all relevant medical evidence and documentation during the initial appeal.

ERISA also limits the damages that can be recovered in disability insurance cases. Unlike other types of lawsuits, individuals cannot recover punitive damages or compensation for emotional distress under ERISA. The remedies are generally limited to the benefits that were wrongfully denied and, in some cases, attorney’s fees.

Bad Faith Insurance Practices

In addition to appealing a denial, individuals may have grounds to sue their insurance company for engaging in bad faith practices. Bad faith occurs when an insurance company fails to act in good faith and fair dealing with its policyholders. Some examples of bad faith practices include:

• Unreasonable Delays: Insurance companies are required to process claims in a timely manner. If the insurer unnecessarily delays the claims process, it may be acting in bad faith.

• Failing to Conduct a Proper Investigation: Insurance companies must thoroughly investigate claims before making a decision. If the insurer denies a claim without conducting a proper investigation, it may be liable for bad faith.

• Misrepresenting Policy Terms: Insurers must be transparent about the terms and conditions of their policies. If the insurance company misrepresents or misinterprets the policy to justify a denial, this could be grounds for a bad faith claim.

• Denial Without a Reasonable Basis: Insurance companies must have a legitimate reason for denying a claim. If the denial is arbitrary or without proper justification, the company may be acting in bad faith.

Filing a bad faith claim can result in additional damages beyond the benefits owed under the policy. In some cases, individuals may be able to recover compensation for emotional distress, attorney’s fees, and punitive damages.

Legal Representation in Disability Insurance Disputes

Navigating a disability insurance claim or denial can be challenging, especially when dealing with large insurers like Unum. Many individuals find that hiring a lawyer who specializes in disability insurance disputes significantly improves their chances of success. A knowledgeable attorney can:

• Review the Policy: An attorney can review the disability insurance policy to determine the specific terms and conditions, including the definition of disability, the requirements for medical evidence, and any exclusions or limitations.

• Communicate with the Insurance Company: Insurance companies often have teams of adjusters and lawyers working to deny claims. An experienced attorney can communicate with the insurer on behalf of the claimant, ensuring that their rights are protected.

• Handle Appeals: The appeals process can be complicated and time-consuming. An attorney can help gather the necessary evidence, file the appeal within the required time frame, and present a compelling case for benefits.

• Litigate if Necessary: If the insurance company refuses to approve the claim, an attorney can file a lawsuit and take the case to court. Many insurance companies prefer to settle rather than risk going to trial, especially if the claimant has a strong case.

Empowering Individuals to Fight for Their Rights

It is important for individuals to understand that they have rights when it comes to disability insurance claims. Insurance companies have a duty to act in good faith and provide benefits when they are owed. While insurers may try to deny claims for financial reasons, individuals are not powerless in the face of these denials.

By understanding the reasons for denials, gathering strong medical evidence, and seeking legal advice when necessary, individuals can take control of their situation and fight for the benefits they deserve. Whether dealing with Unum or another disability insurer, persistence and knowledge are key to overcoming unjust denials.

Unjust denials by Unum and other disability insurance companies can create significant financial and emotional stress for individuals who are already struggling with a disability. However, claimants have options to appeal denials, file lawsuits, and hold insurers accountable for bad faith practices. By empowering themselves with knowledge of the claims process, their legal rights, and the support of experienced attorneys, individuals can fight for the benefits they are entitled to and seek justice against unfair insurance practices.

FAQ

What should I do if my disability claim is denied?

Start by reviewing the denial letter to understand the reasons for the denial. Gather additional medical evidence, file an appeal, and consider consulting an attorney experienced in disability insurance disputes.

How long do I have to file an appeal after a denial?

The time frame for filing an appeal is typically specified in the policy, often limited to a few months. It is important to file the appeal within this deadline to avoid losing the right to challenge the denial.

What is considered a pre-existing condition, and how does it affect my claim?

A pre-existing condition is a health issue or injury that existed before the start of your disability insurance policy. Many policies have exclusions for pre-existing conditions, meaning that if your disability is related to a pre-existing condition, the insurer might deny your claim. It’s important to review your policy's definition and limitations regarding pre-existing conditions.

What types of evidence are important for a successful disability claim appeal?

To strengthen your appeal, gather comprehensive medical evidence including detailed medical records, test results, and statements from treating physicians. Document how your disability affects your ability to work and any other relevant information that supports your claim.

Can my disability insurance company conduct surveillance on me?

Yes, insurance companies may conduct surveillance or hire private investigators to verify the validity of your claim. They may use this information to challenge the legitimacy of your disability, so it’s important to provide accurate and honest information about your condition.

What is the role of a disability insurance adjuster, and how do they affect my claim?

A disability insurance adjuster is responsible for reviewing claims, gathering evidence, and making decisions about benefits. Their role is crucial, as their assessment directly impacts whether your claim is approved or denied. Working with an experienced attorney can help ensure that your claim is handled fairly.

How can I determine if my insurance company is acting in bad faith?

Signs of bad faith include unreasonable delays in processing your claim, failing to conduct a proper investigation, misrepresenting policy terms, or denying your claim without a valid reason. If you suspect bad faith, consult with an attorney to discuss your options for pursuing legal action.

What remedies are available if my disability insurance claim is wrongfully denied?

If your claim is wrongfully denied, remedies may include recovering the benefits owed under the policy, potential damages for emotional distress, and legal fees. In cases of bad faith, additional damages such as punitive damages may also be available.

What should I include in my appeal letter to the insurance company?

Your appeal letter should include a clear statement challenging the denial, a detailed explanation of why the denial was incorrect, and any additional evidence that supports your claim. Be sure to address each reason for the denial and include updated medical records or other relevant documentation.

How long does it typically take to resolve a disability insurance dispute?

The time required to resolve a disability insurance dispute varies based on the complexity of the case, the insurer’s response, and whether legal action is involved. The appeals process can take several months, and lawsuits can extend this timeline further, potentially taking years.

Can I change my disability insurance policy if I’m unsatisfied with how my claim was handled?

If you’re dissatisfied with your insurer, you can seek coverage from a different provider, but this may be challenging if you have pre-existing conditions or ongoing claims. It’s important to review policy terms and consult with an insurance advisor before making changes.

What are the benefits of working with a lawyer specializing in disability insurance?

A lawyer specializing in disability insurance can provide expert guidance, help navigate the complex claims process, ensure that your rights are protected, and improve your chances of obtaining the benefits you deserve. Their experience can be invaluable in handling disputes and litigation.