Experience. Results.

Sometimes insurance providers just make stuff up in their denials

On Behalf of | Aug 9, 2023 | Firm News

Whether they didn’t do their homework, or they simply let ChatGPT write the letter, First Unum Life Insurance Company recently sent a doozy of a fiction-based rejection that the court refuted in short order.

In Graziano v. First Unum Life Ins. Co., the plaintiff contested the termination of his long-term disability benefits and his life insurance premium waiver benefits. The plaintiff’s myriad physical maladies included “persistent (and deteriorating)” pain in his back, shoulder and hip, which included osteoarthritis and lumbar radiculopathy. These conditions prevented the plaintiff from sitting at a desk for prolonged periods, making even sedentary work unrealistic.

The court picked apart two glaring points in Unum’s rationale for terminating benefits.

Unqualified case reviewer, no examination

The lesser of Unum’s two key fumbles involved the casual evaluation performed by their in-house reviewer. This individual made judgements that clashed with what the plaintiff’s board-certified pain management specialist reported regarding the plaintiff’s condition. The court rightly pointed out that the case reviewer, who had no experience in pain management or rehabilitation, who had never seen or spoken to the patient, was not in a position to override a specialist’s diagnosis.

A gross mischaracterization

The pure fiction portion of Unum’s termination of benefits revolved around the plaintiff’s efforts to seek treatment for his conditions. Unum’s representative described the plaintiff’s attempts at rehabilitation as “conservative.”

The court noted that the plaintiff had sought “physical therapy, medical branch injections, steroid injections, and lumbar radiofrequency ablation treatments.” Even to a casual observer, these extraordinary efforts at seeking treatment demonstrate an earnest attempt at achieving rehabilitation, even as his condition worsened.

A lesson in challenging provider rulings

While this particular case could have probably been parsed and accurately resolved by any layperson, it’s worth noting that decisions handed down by insurance companies are sometimes based on flawed logic at best and sheer fantasy at worst.

People who receive a denial of benefits should not consider these decisions as etched in stone. While there are certainly some insurance case reviewers who correctly interpret policy coverage, keep in mind that imperfect humans are doing this work. Sometimes they make mistakes, sometimes they misrepresent the facts and occasionally they stray completely from reality.

If you believe your insurance company unjustly denied your benefits, or if you cannot figure out why those benefits were terminated, consult an ERISA attorney for a second opinion. Find out whether there is a legitimate reason to deny your claim, or whether the insurance company is simply trying to save money at your expense.