A physician resident in Ohio won back their LTD benefits from Unum after suffering a spinal injury, among other issues, after a car accident.
Dr. Sepanta Jalali was a family practice resident and was covered under her employer’s long-term disability plan insured by Unum. One year before her employment, while still in medical school, she suffered terrible injuries in a car accident. The injuries that she suffered, followed by several surgeries, rendered her disabled from working in any occupation.
Unum acknowledged disability She had been on the claim with Unum and being paid long term disability benefits for years. Then, Unum reversed course and termination benefits finding she improved and was able to work in a sedentary occupation.
Following the termination, Dr. Jalali provided evidence supporting her inability to work, including an independent medical examination and a functional capacity evaluation. However, Unum also conducted an independent medical examination and at least two paper reviews by in-house medical reviewers.
What is notable about Unum’s reviews is that they asked the reviewers a specific question — whether Dr. Jalali could work in a sedentary occupation with reasonable accommodation. The problem with asking this question as part of its disability review is that the disability insurance policy does not have any language about whether the disability is based on an ability to work with reasonable accommodation.
In other words, the Court held that Unum misinterpreted the policy by including that analysis in its review. The question of disability, according to the plain language in the policy, does not rest on whether the claimant can work with reasonable accommodation. Under the terms of the policy, Unum need only determine whether or not the claimant can work in any gainful employment, at a minimum a sedentary occupation.
The Court found that Unum misinterpreted the terms of the disability insurance policy by applying a higher standard for determining disability. Thus, all the medical reviews it relied on are without merit.
To that end, the Court awarded in favor of Dr. Jalali. It ordered Unum to pay her retroactive benefits to the date her claim was terminated.
In disability insurance claims, policy interpretation is important. Insurance companies cannot add language to the policy that does not exist. It cannot create a higher standard than what the policy calls for when determining disability.
Lawyers Specializing in Disability Insurance Claims
Because disability insurance law is complicated, it is important to get legal help from a lawyer who focuses on disability law.
As a law firm built to focus on disability insurance, our lawyers specialize in disability insurance. We spend every day working to get our clients long term disability benefits approved.
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If your claim for long-term disability benefits was denied or is delayed by an insurance company, call us to speak with a disability insurance attorney.
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