Monday, June 05, 2006

Insurance Company's Reliance on Flimsy Evidence May be Reason to Overturn Disability Benefits Denial

Although the case is a year and a half old, Stup v. Unum Life Insurance (4th Cir. 2004), shows disabled individuals can prevail in challenging disability benefit denials. The plaintiff suffered from lupus and fibromyalgia. The issue was whether her condition prevented her from performing any gainful occupation.

Unum sent the plaintiff to a functional capacity evaluation ("FCE"). Although the physical therapist ("PT") conducting the FCE concluded that Ms. Stup could perform sedentary work, the PT equivocated because Ms. Stup's condition rendered her unable to complete the evaluation. As such, the PT stated "it would not be prudent to make recommendations regarding specific job duties that this client can or cannot perform due to a lack of consistent and true information." Based on the PT's report, A UNUM doctor concluded Ms. Stup could perform sedentary work.

For her part, Ms. Stup present a lenghty and well-documented medical history demonstrating she could not work.

UNUM denied Ms. Stup's claim. Citing the supposedly conflicting medical evidence above, UNUM claimed that under the deferential standard of review applied to these cases, the Court should affirm the benefits denial.

Not so, the Fourth Circuit held. To defer to an insurance company's decision, it must produce "substantial evidence" supporting its decision. The FCE was not substantial. According to the Court:

[An insurance company] does not act reasonably in denying benefits if faced, on the one hand, with substantial evidence of disability and, on the other, with only tentative and ambiguous evidence that might, or might not, favor denial of benefits. This is precisely the situation at hand.


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