Unum Denial Based on Nurse’s Recommendation

Baltimore, MDIt’s bad enough that Unum, or First Unum terminates disability benefits based on its independent medical examiner’s opinion. But denying a policyholder further long-term disability based on a nurse’s recommendation is unconscionable.

Kimberly first collected workers compensation benefits when she was injured on the job. Over the years her injury worsened and she had several foot surgeries - almost a reconstruction. Her last surgery didn’t go well and she suffered nerve damage. “I wound up in a pain management treatment center, diagnosed with Chronic Regional Pain Syndrome,” Kimberly says. The surgeries couldn’t help permanent nerve damage and by 2012, she was completely disabled.

“I had to leave Baltimore to visit my father - he had terminal cancer,” Kimberly explains. “Because I missed a few physiotherapy appointments, workers comp cut me off. Unum was great; they actually increased my benefits to make up for the lost income from workers comp. Shortly afterward I received a letter from Unum, explaining that I didn’t tell them about a workers comp settlement in 2009 (my case was reopened due to nerve damage in my foot) so they would deduct $300 per month moving forward.”

Kimberly didn’t know that she was supposed to report the settlement to Unum - she has no record of the insurer requesting such information. Unum did request that Kimberly apply for Social Security benefits but she was denied. Next up, Unum hired a third-party company called Genex to represent her - to assist with her appeal.

“Genex let the appeal date for my Social Security benefits expire so I was disqualified,” says Kimberly. “The judge said my attorney had two weeks to get her ‘ducks in a row.’ I went before a judge for a second appeal and this time the Genex attorney was prepared - or so I thought. The attorney got together all my medical records in time but Social Security denied me again - I was never told why.”

Kimberly received her last long-term disability check from Unum last year, explaining that she was cut off because the nurse at Smart Pain Management told her Unum rep that she was able to return to work full-time.

“She had never discussed with me whether or not I could work and no one at the clinic had ever given me a complete evaluation. In fact I am getting worse. Last November I wound up in hospital for a week: I couldn’t walk because a cyst ruptured behind my knee. Apparently the cyst is secondary to the arthritis I have.”

More than anything, Kimberly wants to work. She has no income and her house is up for sale because she missed so many mortgage payments. Kimberly lives alone, in her grandmother’s house. She worked for the defense department, in a fast-paced, fast-thinking environment. Now she moves slowly because of her foot and she adds that the pain meds don’t comply with that kind of work environment - they slow down her thinking.

“I appealed my case to Unum and they gave me until last month to gather medical reports about my knee. I have been trying to do that but the hospital isn’t cooperating. Just last week I talked to my Unum rep. ‘Well, it’s getting too late now,’ she said. I don’t think they want to help me at all; they just want to cut me loose. Why can’t their independent medical examiner look at my records or even better, examine me?”