In Linda M. Hines v. Unum Life Insurance Company, Plaintiff was covered under a disability benefit policy through her employer. A provision of that policy was that it did not pay benefits for any disabling condition for which the employee had received medical treatment during the three-month period before the employee became covered under the plan.

It was undisputed that Plaintiff received cataract surgery in her right eye during the three-month period. Eight months later, on May 14, 2014, she was diagnosed with anisometropia, “a neurologic condition where the brain becomes unable to mesh the separate images given by each eye.” She filed a claim for long-term disability (LTD) benefits and on October 31, 2014, Unum denied her claim. On December 14, 2014, Unum upheld its denial decision.

Unum argued that the anisometropia was caused by her pre-existing cataract surgery. Plaintiff argued that the medical condition was not related to the cataract surgery, but a totally separate condition. Despite medical records supporting her claim, Unum still denied her LTD benefits. After exhausting her administrative remedies, she filed this ERISA lawsuit.

The U.S. District Court for the Northern District of Ohio held that Unum abused its discretion in denying her LTD benefits for her cataract, since that was not the basis of her disability claim. It also abused its discretion in finding thatanisometropia was a pre-existing condition. The Court awarded Plaintiff attorney’s fees and costs.

Plaintiff Did Not Claim Her Left-Eye Cataract was a Disabling Condition

Unum’s decision to deny LTD benefits rested, in part, on its assertion that the left-eye cataract was a pre-existing condition. Plaintiff’s claim for LTD had nothing to do with her left-eye cataract, so to deny her benefits on this basis was an abuse of discretion.

The Evidence Did Not Support Unum’s Decision that Anisometropia Was a Pre-Existing Condition

The Court reviewed the complete medical records of Plaintiff’s treating physicians as well as the reports of Unum’s medical reviewers and concluded that, “No substantial evidence supports Unum’s decision that Plaintiff Hines anisometropia was a pre-existing condition not covered by the Plan.” In fact, the Court noted, “The evidence actually supports the opposite conclusion.”

No Evidence Supports Unum’s Argument that the Anisometropia Resulted from the Pre-Existing Right-Eye Cataract Surgery

The Court rejected Unum’s argument that the right-eye cataract surgery, which was a pre-existing condition, caused the anisometropia. The Court noted that Plaintiff did well following that surgery and there were no complications. There was no substantial evidence to support that the diagnosis of anisometropia eight months later was in any way related to the right-eye cataract surgery.

Plaintiff Was Entitled to Attorney’s Fees and Costs

The Court found several factors supported awarding Plaintiff attorney’s fees and costs in that Unum:

  • Inaccurately represented physician statements.
  • Omitted potentially relevant medical information.
  • Followed up with reviewers in a way that suggested, “try again.”
  • Cherry-picked language from reviewers who seemed to “dance around the questions…”

The Court held that an attorney’s fee award will deter Unum and other insurance companies from similar conduct in the future.

This case was not handled by our office, but we think it may be helpful to those who are trying to convince their insurance company that their disability claim is not based on a pre-existing condition. If you have questions about this case, or any aspect of your disability claim, contact one of our disability attorneys at Dell & Schaefer for a free consultation.