Unum / Provident / Paul Revere

 In Hoang N VS Unum Life Insurance Company of America and Northrop Grumman Long Term Disability Plan, Plaintiff wants reinstatement of long term disability payments that were originally paid, then terminated, by Unum.

The Plaintiff, with the help of his California Disability Attorney, has filed this lawsuit in the United States District Court Central District of California against Unum.

Plaintiff’s History and Reasons For Filing a Claim

Plaintiff worked as a systems administrator and network engineer at Northrop Grumman. His employment entitled him to be a participant in the Long Term Disability plan and other employee benefit plans that were established and maintained by Northrop Grumman.

Plaintiff suffered serious injury to his cervical spine when a heavy metal door fell on his head at work and knocked him to the ground unconscious. This accident caused the Plaintiff to become disabled as defined under the terms of the LTD Plan. Plaintiff filed a claim with the Defendants for LTD benefits under terms of the Plan. The Defendants originally approved the claim for LTD benefits.

Unum and Northrop Grumman Improperly Terminate Long Term Disability Benefits

On or about November 4, 2008, Defendants abruptly terminate the LTD benefits received by the Plaintiff. From the period of November 2008 through June 2009. Plaintiff’s doctor reports that the Plaintiff was suffering from the following conditions:

  • Dysphoric mood
  • Excessive worrying
  • Insomnia
  • Confusion
  • Irritability
  • Lack of appetite
  • Intermittent suicidal ideation
  • Social isolation
  • Paranoia

Plaintiff filed an appeal of Defendants’ denial on June 12, 2009. Unum replied to Plaintiff on June 15, 2009 that they could not review Plaintiff’s claim because the appeal came after the 180-day deadline, meaning that the original decision on the claim must stand.

After Plaintiff received a Social Security Administration decision in his favor, Plaintiff again requested that Defendants reinstate his long term disability benefits on April 25, 2011. Once again, on May 2, 2011, Defendants deny Plaintiff’s request.

Due to the fact that Plaintiff has exhausted all administrative remedies required under ERISA, Plaintiff has filed this lawsuit against Unum and Northrop Grumman.

Basis for Plaintiff’s Lawsuit

Plaintiff claims that Defendants failed to allow Plaintiff to file an administrative appeal against California’s notice-prejudice rule, which only prevents a person from filing an administrative appeal after a deadline if the Defendants are actually and substantially prejudiced by the delay. Plaintiff also claims that Defendants prevented Plaintiff from filing an administrative appeal when Defendants knew that the Plaintiff was suffering from severe cognitive problems.

Plaintiff also claims that Defendants did not provide any reasonable explanation of why Plaintiff’s appeal was not considered, nor why his original claim was denied. Defendants also did not provide any explanation of what materials could have been added to increase the chances of a successful claim.

Plaintiff also claims that Defendants failed to adequately inform the Plaintiff of notice requirements under ERISA. Additionally, Defendants failed to properly investigate the merits of the Plaintiff’s claim.

Type of Relief Requested from the Court

Plaintiff requests that the Court grant the following relief:

  • Plaintiff is able to file an administrative appeal of the denial of his original claim
  • The administrative appeal will be given full and fair consideration
  • All associated costs are paid
  • All appropriate attorney fees are paid
  • All other relief decided upon by the Court is fulfilled

About the author: Gregory Michael Dell is an attorney and managing partner of the disability income division of Attorneys Dell & Schaefer. Mr. Dell and his team of lawyers have assisted thousands of long-term disability claimants with their claims against every major disability insurance company. To request a free legal consultation call 800-411-9085.

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History of Plaintiff

Plaintiff, who is 46 years old, worked as a machinist at two companies in Bristol, Connecticut for a total of 16 years. He then worked as an Electrical Discharge Machine Operator at EDAC Technologies Corporation (EDAC) in Farmington, Connecticut since 2000. His job required him to position and secure workpieces on a table using clamps; measure parts; manually input data into a computer; and regularly exert between 10 and 50 pounds of force with his hands to move objects.

Plaintiff suffers from gout, a form of severe arthritis characterized by joint pain, tenderness, and reduced mobility in the areas affected. These areas usually include the hands, wrists, feet, and ankles. wrists, feet, and ankles. This medical condition causes him consistent severe pain, occasional complete immobility, and a regular inability to use his hands, wrists, feet, and ankles for almost anything, including grasping, pushing, holding, walking, and standing. His dominant (right) hand and wrist are affected more than his non-dominant hand and wrist. Plaintiff first suffered from gout approximately 20 years, and it has worsened progressively over the years.

Due to the continuing deterioration of his gout, Plaintiff can no longer operate as a machinist or in any other occupation. This has been the case since late-September 2010. Plaintiff takes powerful prescription drugs to combat the consistent pain, but the serious side effects from these medications include lightheadedness, forgetfulness, nausea, and fatigue. These prevent him from driving a motor vehicle or operating other types of machinery and industrial equipment.

Plaintiff filed an application for benefits under EDAC’s Unum Plan in September 2010. He was to have received 60% of his "monthly earnings" until a maximum age of "Social Security Normal Retirement Age." According to the terms of the Plan, the Plaintiff satisfied the definition of being disabled both regarding his own occupation (first 24 months of benefit collection) and any other occupation (after 24 months of benefit collection).

Unum Denies Claim

On June 29, 2011, Unum denies Plaintiff’s benefit application due to the reason that the medical evidence did not support that his gout was disabling under the Plan’s definition; he did not satisfy the Plan’s requirement that he work 35 hours per week prior in order to qualify for benefits; and he held another part-time job that he did not disclose to Unum, which disqualified him from benefit collection.

Plaintiff filed an appeal on September 24, 2011 disputing these reasons, which Unum essentially admitted as being true and that it was mistaken in Plaintiff having a part-time job. Plaintiff added 68 pages of medical records, letters from his physicians, Unum’s internal claim evaluation notes, and seven sworn records to his appeal.

Plaintiff underwent wrist surgery in fall 2010. His surgeon said in June 2011 that he will have no use of his right hand and wrist, further strengthening Plaintiff’s claim that he is disabled under the terms of the Plan. A fusion procedure that is recommended for the Plaintiff would prevent him from undertaking any gainful employment that requires Plaintiff to use his right hand to any significant degree.

Plaintiff also demonstrated that he has done no work for his wife’s vending cart business. Plaintiff also showed that he briefly dropped under 35 hours of work per week due to gout flare-ups in his feet.

Despite showing all of this, Unum denied Plaintiff’s appeal on October 20, 2011 on the same reasons as its original denial. Due to exhausting all administrative remedies, Plaintiff has filed this lawsuit against Unum.

Reasonings Behind the Lawsuit

Plaintiff claims that Unum’s failure to pay these benefits was wrongful, arbitrary, capricious, and otherwise unlawful. Additionally, Unum also chose to disregard the opinion of its own claim reviewer nurse who stated that "it is unlikely that the insured will regain his premorbid level of" functional capacity.

Unum also never requested that Plaintiff undergo an independent medical examination or functional capacity evaluation so that it could attempt to determine the severity of his gout or its impact on his ability to work in his own job or others.

Requested Relief

Plaintiff wants the following relief to be granted by this Court:

  • Payment of all unpaid monthly disability payments
  • All prejudgment interest
  • Costs associated with filing this lawsuit
  • All appropriate attorney’s fees
  • Reinstatement of Plaintiff’s eligibility for continued disability benefit payments in the future
  • All other relief deemed proper by this Court 

About the author: Gregory Michael Dell is an attorney and managing partner of the disability income division of Attorneys Dell & Schaefer. Mr. Dell and his team of lawyers have assisted thousands of long-term disability claimants with their claims against every major disability insurance company. To request a free legal consultation call 800-411-9085.

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On June 22, 2007, the claimant became disabled due to "a series of physical medical conditions, inter alia, a variant of Dejerine Roussy (Central Pain) Syndrome called central hypoperfusion syndrome, fibromyalgia, severe immunodeficiency, and server adrenal deficiency." Suffering from "chronic disabling pain of her right lower abdomen, whole body pain of muscles, joints and bones (including sensations of severe numbness and burning in her legs, face and neck, irritable bowel syndrome, dizziness and nausea, severe fatigue, severe migraine headaches, and chronic hormonal imbalances," the claimant takes powerful corticosteroids and other medications that cause side effects of cognitive difficulties, sleepiness, dizziness, fatigue and other symptoms that preclude her from performing her occupation as a Morgan Stanley Banking Associate.

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Unable to perform "the substantial and material duties of her prior occupation as a Banking Associate," the claimant applied for long term disability benefits from UNUM, and was awarded those benefits on November 13, 2007. Approved for $5,000 per month in disability benefits, the claimant’s disability benefits were calculated incorrectly by taking into consideration only Sconiers’ base salary and failing "to calculate her basic monthly earnings as her HWEE defined as prior year annual gross W-2 earnings" as specified by the UNUM plan. In addition, without "conducting any reasonable or thorough investigation" and without having evidence supporting that the claimant’s condition had improved, UNUM terminated her disability benefits on March 24, 2010. The insurer asserted that the claimant "suffered from a mental condition" that had passed the disability plan’s 24-month limitation period and thus she "was no longer disabled under the terms of the Group Policy."

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After filing several appeals to UNUM’s termination and miscalculation and being denied at every turn, the claimant and her disability attorney filed the subject lawsuit to obtain her entitled disability insurance benefits through litigation. Alleging that the insurer violated ERISA (the Employee Retirements Insurance Security Act of 1974), California law, and its fiduciary duty in respect to the management of her Stanley Morgan disability insurance plan, the claimant and her California disability attorney accuse the insurer of:

  • Denying benefits based upon an incorrect interpretation of total disability as defined in the plan;
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  • Miscalculating the disability benefits the insurer did pay to the claimant; and
  • Improperly "interpreting disabling medical conditions as mental illnesses or psychological conditions."

The claimant and her disability attorney, in her complaint, ask the District Court to permanently enjoin UNUM from "ever again serving as a fiduciary with respect to the Plan," award the claimant attorney’s fees and costs, provide the claimant with appropriate equitable relief from UNUM and issue an order awarding the claimant the "full amount of benefits due since November 13, 2007," plus interest and "other losses resulting from UNUM’s breach."

About the author: Gregory Michael Dell is an attorney and managing partner of the disability income division of Attorneys Dell & Schaefer. Mr. Dell and his team of lawyers have assisted thousands of long-term disability claimants with their claims against every major disability insurance company. To request a free legal consultation call 800-411-9085.

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