Michail Hack, Partner; Stephen Broer, Of Counsel; and Christine Kingsley, Claims Paralegal
The Challenge
A medical professional suffering from multiple disabling conditions could no longer perform the duties of their profession and filed a claim with their long-term disability (LTD) insurance provider, UNUM. The professional had a special policy that provided benefits if they were unable to perform the material duties of their specific occupation (known as “own occupation” coverage) from the date of disability until retirement age. As this is a much longer period than more common policies, which typically limit the own occupation period to just two years, the insurance company had a significant financial incentive to avoid coverage. The insurer denied the policyholder’s claim for benefits in 2024.
The Solution
Following the denial, the medical professional came to Schwartz, Conroy & Hack. Understanding the insurance company’s financial incentive to deny coverage, we developed a comprehensive strategy to best position the claim for approval. This was particularly challenging since our client suffered from many co-morbid conditions and treated with multiple healthcare providers for the various disabling conditions.
The claim was governed by ERISA (the Employee Retirement Income Security Act of 1974). Insurance companies handling ERISA-governed claims are under tight deadlines. For this reason, UNUM sought to limit the amount of time that our client had to present all supporting evidence.
However, claimants are not bound by ERISA’s time constraints. They can unilaterally extend the appeal period to accommodate additional documents, information and statements from treating healthcare providers to support their appeal. Knowing this, we forced UNUM to recognize that it could not unilaterally limit the timeframe for our client to present all relevant evidence. We also reminded UNUM that it had previously signed a multi-state settlement agreement whereby it agreed to give deference to treating healthcare providers. UNUM was forced to concede these points, and the appeal remained open until all supporting evidence could be properly filed.
The Result
Our tenacious team of Partner Michail Hack, Of Counsel Stephen Broer, and Claims Paralegal Christine Kingsley successfully worked to hold UNUM accountable to its obligations, and the insurer eventually agreed to honor the claim and pay our client’s full benefits. Schwartz, Conroy & Hack forced the insurance company to keep the promises it had made when our client had purchased the policy.
