Our client was a doctor’s office staff who had been diagnosed with, primarily, fibromyalgia, trigeminal neuralgia and chronic fatigue. One major problem with the case was that when we asked Unum for the “entire claim file,” they only sent us about half of it.
In other words, they left us without complete knowledge while writing the appeal. Unum terminated benefits for 3 reasons:
First, The client had been denied in light of “two in house reviews” which posited that she wasn’t disabled enough. Basically, they accepted the diagnoses and that there were limitations, but contested the extent of those limitations.
Problematically, in claiming that the claimant wasn’t functionally disabled enough, Unum had falsified what the medical records conveyed. In fact, Unum asserted that a specific quote came from a medical record which, in fact, contained nothing even remotely similar to what was reported.
Second, Unum also claimed that there was no evidence of a fibromyalgia flare when, in fact, there was plenty of evidence of it. Patterns of doctors visits and doctors notes actually illustrated the existence of a flare up.
Third, Unum asserted that there was no evidence of “muscle weakness, atrophy, or neurologic deficits.”
However, the claim file contained a 1 page note from the claim rep discussing the report and evidence of “muscle weakness” and how it impacted the claimant’s life.
Testimonial support letters reinforced the existence of muscle weakness and visible muscle atrophy of the arms. In the end, Unum conceded the client was disabled and reinstated benefits, including past due benefits. A total of which was: $183,911
