Well, What Does The Policy Say?

We all know insurance companies love to take your premium money and then find reasons to deny or limit your claim. Here’s a case where Unum Life Insurance Company of America (“Unum”) tried to shift the burden of proof to our client, and how we helped him.

While moving a crate at work Mr. Moore (not his real name but a real client) developed pain and swelling of his left knee. His x-ray was normal, and his physician diagnosed internal derangement of the left knee and sprain/strain, prescribed physical therapy, and placed him on modified duty. With no improvement upon reevaluation his physician ordered an MRI, but three weeks later it hadn’t been scheduled. Since Mr. Moore reported feeling 90% better, his physician released him to full duty to do his heavy-duty job with no restrictions and assigned 0% impairment rating.

A month later Mr. Moore fishtailed his motorcycle upon braking causing a wreck. At the Emergency Room he complained of left knee pain and inability to bear weight. His physician found ligament laxity and deep abrasions at multiple sites but no fractures.

After an MRI revealed lateral meniscus tear and complete tear of ACL, his physician scheduled surgery, and Mr. Moore filed a claim for short-term disability (STD) benefits under his employer’s disability plan. Unum denied his claim based on worker’s compensation exclusion advising that there was no positive exam finding that his condition wasn’t work-related. Unum’s review physician noted “the available information that was received does not fully explain which injury contributed to or caused the ACL tear and meniscus tear that required knee surgery.” Fueled with that opinion, the claim manager notified Mr. Moore that “there was no ability to determine that his condition is not work-related.”

A knowledgeable ERISA attorney like me knows that under ERISA, an insurer bears the burden to prove facts supporting an exclusion of coverage.

Unum’s statement that “there was no ability to determine that his condition is not work-related” was an attempt to unfairly shift the burden of proving the exclusion of coverage to Mr. Moore. We successfully argued that Unum could not meet its burden of proof and Mr. Moore received the STD and LTD benefits he deserved. Case Closed!