Employees in Chicago with claims for long-term disability benefits have often been requested by the long-term disability insurer to attend an Independent Medical Examination, or IME. Often this is sign the insurer is looking to deny the claim or terminate ongoing benefits. Rightfully so, most claimants dread the IME. They are rarely “independent,” because insurers always hire the same group of vendors to assign the IME doctor. But on occasion, the insurer not requesting an IME can help your claim, and it may be helpful to request the insurer perform an IME. A recent case demonstrated when it can be advantageous to ask the long-term disability insurer to perform an IME.
In Moseley v. Unum Life Insurance Co. of America, No. 22-40079, 2023 WL 2324771 (D. Mass. Mar. 2, 2023), Ms. Mosely claimed long-term disability benefits due to chronic Lyme Disease. Unum approved her claim. But two years into paying benefits, Unum applied a 24-month mental health limitation to Moseley’s claim, asserting her disability was psychological, and not due to Lyme Disease. Moseley requested Unum perform an IME regarding the origin of her limitations. Unum declined, and proceeded to uphold its benefit termination. Moseley then sued under ERISA § 502(a).
The United States District Court for the District of Massachusetts ruled against Unum and in favor of Moseley. The court referred to a regulatory settlement agreement between Unum and several states in which Unum agreed it would request an IME whenever the claimant or a claimant’s attending physician requests an IME, directly or through the claimant’s representative. Unum’s failure to follow its agreed-upon rules for handling claims rendered the benefit termination arbitrary and capricious. The court reversed the denial and remanded the matter to Unum to consider the claim in accordance with the opinion. It also allowed Moseley to move for an award of attorney’s fees and costs.
If your claim for long-term disability benefits has been denied or terminated, talk to an experienced ERISA long-term disability lawyer immediately to secure your rights to a full and fair review by the insurer.