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US insurance company loses Fibromyalgia lawsuit

Tuesday 11 February 2014




Disability Insurance Policy

Unum Still Denying Fibromyalgia but Unum Loses Lawsuit

February 4, 2014, 04:00:00PM

Woodville, TX: Incredibly, Unum, or Unum Provident still doesn’t recognize that fibromyalgia is a physical disease, not mental. Unum did acknowledge Susan’s disability briefly: she received short-term and long-term disability benefits, but last December, she was abruptly cut off - without so much as a warning.

Susan, a schoolteacher, was approved for Social Security benefits, which is precisely what Unum was hoping for. “If Social Security recognizes fibromyalgia as a physical disorder, I can’t understand why Unum is allowed to deny or stop benefits to their policyholders,” says Susan. “According to Unum’s policy, they will pay one year for a mental disability and they are claiming that fibromyalgia is a mental disability. But I have done my research and they are wrong!”

Despite Susan paying into her Unum policy for many years, the Unum Group cut her off with the excuse that she didn’t have enough documentation for her neurosurgeon’s diagnosis of bulging discs in her neck and back - they didn’t even address fibromyalgia in reasons for denial.

Susan has undergone several surgeries for endometriosis and lesions since 1997; by late 2012, she’d had enough. “My body was done with all these surgeries and my doctor deemed me disabled,” she says. “At that time I was seeing so many specialists and my neurosurgeon was giving me a series of injections to treat pain but I wasn’t getting any better. And these specialists said I was able to go back to work, but nobody wanted to look at the ‘whole’ picture. I feel like the specialists don’t want me to be disabled.”

For instance, Susan’s gastroenterologist had no idea how much she was suffering from fibromyalgia and her neurosurgeon figured she could return to work because her bulging discs could be under control - never mind the rest of her body. “I think these specialists said I could return to work because they couldn’t be bothered to fill out the forms and explain why I should stay on disability except for this internist I saw last month,” Susan adds.

Last August Susan’s internist explained that, because she has been on so many medications, her current state of health “is as good as you are going to get” and she won’t be able to teach school again, particularly special education. “Before this fibromyalgia overwhelmed me, I took kids to livestock shows and I even hauled animals there,” Susan says. “At our school they expected you to do little things like that, but I could no longer do anything extracurricular. After a regular day of teaching I would have to come home and take a three-hour nap.”

Interestingly, Susan didn’t see one of Unum’s Independent Medical Examiners. Instead, Unum decided that Susan was fit to return to work, sight unseen. Before she was approved for Social Security benefits, however, Susan was sent to a psychiatrist to determine whether her illness was mental or physical. Of course it was obvious: for instance, Susan has so much nerve damage in her legs from multiple surgeries that she can’t even drive. Her Social Security benefits kicked in immediately.

“I tried to go back to work, I really tried my best,” Susan says. “I probably could go back to work if not for the fibromyalgia. When I got cut off, I phoned my Unum representative. He said. ‘We are done here,’ and dismissed me. I know I cannot fight them by myself - I need a lawyer to help me, to prove that this disease is physical.”

In 2002, Unum published a white paper titled A Fibromyalgia Process Proposal stating the following:

The vast majority of individuals labeled with fibromyalgia have no physical impairment; they are on a physical basis able to return to work (especially with appropriate care). Generally, continued activity (including work) is of value even in the face of symptoms…In summary, Unum’s contributing physicians proposed getting involved early with the insured’s primary care physicians in order to prevent a disability from being supported. Recommendations were also made in the report for detailed phone interviews, nurse-to-doctor and doc-to-doc calls for the purpose of Unum’s early intervention of a disability due to fibromyalgia. Unum’s general consensus or understanding of the disease, as indicated in the position paper, is that fibromyalgia is NOT a physical disease, is “somatoform” (imagined), and that with a little persuading of the doctors, in most cases the insured could return to work full time.

It’s about time that Unum revised its policy. Last year Tracy Mondolo, who suffers from fibromyalgia, filed a Unum lawsuit with the U.S. District Court for the Central District of California after the company denied her benefits. The federal court took into account Unum’s history of unfairly denying claims and Ms. Mondolo won her case against Unum.


The above, with comments, originally appeared here.



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