admin appeal denied (disability insurance)

[pooh1965]

hi. i had appealed my std/ltd with unum back in sept. they originally denied me due to not being under the regular care of a physician (which i have been all along). now i received my administrative appeal letter, of which once again was denied, not due to the original reason but now due to regular occupation. it also appears they are changing it from regular occ to any occ, as they stated i should have found a differnt job in sept. due to problems at work. however, according to my medical records, my illness/condition is not only limited to work related issues. their "medical dept" reviewed my claim, and stated due to a family members letter stating i had severe panic attacks, mostly caused from work, that i have had a very difficult time coping in life. unum is not considering the other letters they received from other family/friends which state issues with stress/anxiety/depression due to family issues as well. unum claims i should have returned to work in sept, however neither my doc or therepist returned me to work, nor did either fill out the required fitness for duty papers in order for me to return to work. thus, i was not returned, and i was still disabled. unum claims there is no impairment noted after a certain date, however, this is also untrue,as my physician and therepist have both noted severe impairments after sept. my therepist also called unum a few weeks ago when i was in the office, and i heard the conversation. she advised unum i cannot work at this time. unum is still denying benefits for std and ltd claiming i seek a new occupation elsewhere as to not cause my stress and depression. there is nothing stated in this letter that implies i can deny this appeal. is this the final word? is my administrative appeal over? now federal court? i cannot find anyone to assist me in this matter. this is an erisa case. unum claimed i was fine up until they denied my benefits and then at that time i became frustrated, angry and believed in my own thoughts that i was entitled to longer time off of work, and be paid benefits too. well, if i am disabled and i have medical proof of this disability, yes, i should be entitled, and yes, i should be angry and frustrated that it has taken over seven months of delaying my claim. any suggestions would be very well appreciated at this time. could i sue my employer for non payment of a valid claim since they issued this policy and the policy states if unable to work due to disability, you are protected by disability benefits? thank you... (arizona)

 

[ALawyer]

It's time for a lawyer.

Disability companies, being hit with more claims, are being "tight" on granting benefits. And, let's face it, there are a lot of people who instead of getting laid off or fired, recognize they can't easily find another job in a slow economy, and so are trying to get STD and LTD benefits that they would never have thought of getting ina good economy and are really not entitled to.

UNUM is not bound by your physicans' findings. Howver, if you "did it yourself" rather than retain a lawyer to help you with your filing, my sense is that what you presented by way of your doctors' findings and other "evidence" was not presented to UNUM in as professional or persuasive manner as possible. Had they been it often results in a different administrative determination.

The next step is likely to force you to go to court, and for that you'd need a lawyer. Some lawyers may perpare and send a petition for reconsideration, and if your case is strong enough, that may get a company to pay, as it knows that once a lawyer is involved you are serious and the insurance company does not want to bear the expense of defending a case that is a likely or possible loser if they can avoid it.

Lawyers will NOT usually take these ERISA cases on a contingency basis as they can not use the potential to collect punitive damages for the insuer's possible bad faith a a bludgeon to pressure a settlement. So you likely will have to spend some money upfront on lawyer fees.

A social securrity disability lawyer (even though yours is NOT an SSD case - although if you had SSD the insurance company might reconsider too) may assist you, as might an insurance or personal injury or general practice lawyer. But it will cost you something to collect, and my sense is if you had spent something earlier on having a qualified lawyer prepare your case you may have avoided spending more now.

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