In Cara R. Denney v. Unum Life Insurance Company of America, plaintiff worked for Wagner Equipment Company as a Computer and Technology Instructor. She said the job required extensive computer use and the ability to instruct students accordingly. It also required her to travel, stand for long periods of time, and carry heavy equipment up to 25 pounds.

In June 2015, she underwent bilateral reconstructive surgery on both of her feet and received short term disability benefits from Unum. She returned to work on a part-time basis in October 2015.

Meanwhile, during her recovery from the foot surgery, she was treated for neck and back pain to a degree that her treating physician opined in January 2016 that she was totally disabled. He said it was unlikely that she would ever be able to return to work.

On January 16, 2016, Plaintiff filed a claim for long term disability benefits asserting she was disabled due to the problems with her feet and her back pain, with the pain from her neck radiating down her arm. Unum denied her claim stating she had not met the requirements of the elimination period since she was disabled for only 175 days before she returned to work and the elimination period was 180 days. Unum also said she was able to perform all the duties of her own occupation. After she exhausted her administrative appeals, she filed this ERISA law suit.

Confusing Policy Language Concerning Elimination and Accumulation Periods

The Plaintiff and Unum had different interpretations of the 180 day elimination period. Plaintiff argued that the 180 days did not have to be consecutive, with Unum taking the opposite position. The Court found Unum’s interpretation of the elimination and accumulation phrases confusing. The court remanded the case to Unum to “further clarify the reason or reasons for its denial of Ms. Denney’s claim, and then, if relevant, the applicable policy language regarding the elimination and accumulation periods.”

The court noted that the law requires that “an insurer’s decision for denying a claim must be clear so as to allow the insured an opportunity to properly respond to the denial.” Since Unum’s reasons for its denial were unclear, the Court remanded to Unum with the following instructions:

  • To provide a full explanation of how the elimination period is applied in conjunction with the accumulation period.
  • To carefully explain to Plaintiff why the accumulation period applies to her claim, if Unum determines that it does.

Determination of “Own Occupation”

Unum’s Vocational Rehabilitation Consultant (VRC) used the Dictionary of Occupational Titles and determined Plaintiff’s position was that of a Training Representative. This was how the job was performed in the national economy, but not necessarily in the Plaintiff’s specific location. The Court agreed with Unum “that an insured’s occupation is defined by how it is normally performed in the national economy, and not by how the individual insured performs it.”

This case was not handled by our firm, but we believe it can be instructive to those who have questions about the accumulation and elimination clauses and the definition of their own occupation. If you have any questions about this or anything else about your disability claim, contact us at Dell & Schafer for a free consultation.