Long Term Disability claim denied, based on a quickie “walk-in” review by insurance company doctor.
Sharon Ray vs. Long Term Disability Plan of Tenet Healthcare Corporation (Unum-Provident) SACV-04-925 DOC
Ms. Ray had a Masters Degree from Brandeis University. She was as Regional Director for Tenet Healthcare, overseeing 10 hospitals. She had a 20-plus year background in healthcare services planning and administration.
She also had a long history of back problems, which grew progressively worse, to a point where she could no longer work. She loved her job and struggled to find ways to keep doing it. She tried to cut down her work time. She tried working from home. She tried coming home for a few hours to lie down before going on to the next hospital that she was charged with overseeing. She tried coming home early and working up her notes, while in bed. Her treating neurologist took her off work for a few weeks, to see if rest would help resolve her problems. It didn't.
Ms. Ray’s job involved long hours, and significant contact with physicians, often at breakfast or dinners. She was also required to represent the company at social functions. It got to a point where she did not have the strength to attend those functions. She struggled to get through such things as luncheon presentations, but found that she was increasingly exhausted from fighting the pain. The demands of her position required both strength and leadership skills. She had lost both.
One day while driving home she received a major scare (or wakeup call). She suddenly noticed that her ability to operate the brake and accelerator was seriously impeded, creating a dangerous situation. She said that at that point “I knew that I was in big trouble”. Her neurologist ordered her off work, but her condition never improved. Finally, as a last resort she filed a claim for long term disability benefits.
Ms. Ray’s diagnoses included, scoliosis, herniated disk at L5-S1, sciatica, right S1 radiculopathy with arachnoid scarring. Despite overwhelming evidence supporting her disability, Unum-Provident denied her LTD claim, based on the opinion of a reviewing doctor, who simply did a quick “walk-in” review, at which he parroted the remarks of a reviewing nurse. The opinion of the treating physician was simply dismissed. Based on nothing more than this, Unum-Provident concluded “we feel that the restrictions and limitations given by (the treating physician) are overly restrictive and not reasonable.”
Result: A lawsuit was filed. The case was resolved satisfactorily.