An Analysis of Unum's Internal Disability Claim Medical Review Process and Associated Litigation

UnumLong Term Disability InsuranceDenied LTD Benefits

Apr 12

Bad guys will always find a way.

Whatever brought you here, I hope we can make a difference.

I. Introduction

When I started my career in 2006, all I did was work on submitting requests for reconsideration under the RSA and CSA that Unum companies had entered into with all 50 states. What dawned on me in the years since then is that 2005 Regulatory Settlement Agreement (RSA) and California Settlement Agreement (CSA) did not change Unum, but it made them much better at “papering” a denial of benefits, and thus much harder to defeat in court. I wanted to explore if I could find support for that gut feeling. This blog is the result.

Share your story. Have you had a challenging experience with Unum's disability claim process? Leave a comment below and join the conversation. Your experience could help others.

Purpose and Scope: This blog provides my analysis of the internal medical review processes employed by Unum Group and its subsidiaries (collectively "Unum") in the adjudication of disability insurance claims. My analysis focuses specifically on identifying and defining the roles of internal medical personnel, such as the "Disability Medical Officer" (DMO); investigating the existence and structure of multi-step internal medical reviews, particularly those involving sequential assessments by multiple Unum-affiliated doctors; and examining the legal scrutiny these practices have faced, especially concerning their use to counter the opinions of claimants' treating physicians. The findings and analysis presented herein are based exclusively on the provided research materials and my experience.

Key Areas of Investigation: My investigation centered on four primary objectives: (1) defining the role and function of the DMO or similarly titled positions within Unum's claims review hierarchy; (2) identifying evidence supporting a multi-layered internal medical review structure, including processes where sequential reviews may be used to reinforce claim denials or terminations; (3) analyzing legal precedents, including court case summaries and regulatory settlements, that discuss Unum's internal medical review procedures, the influence of its medical consultants, and patterns of multiple internal reviews being utilized against claimants; and (4) synthesizing these findings to determine whether such multi-step review processes represent formally documented procedures or a pattern of practice frequently identified and contested in litigation.

Intended Audience: This blog isn’t your typical puff piece aimed at the algorithms, trying to drive SEO. So I decided to give this warning at the start. This is prepared for an audience comprising legal professionals, sophisticated disability claimants engaged in or considering appeals or litigation against Unum, and insurance industry analysts or advocates.

II. Context: Unum's Claim Review Practices Under Scrutiny

Historical Background: Unum, a major provider of disability insurance, has a documented history of facing scrutiny regarding its claims handling practices. Numerous sources describe a reputation for claim denials and allegations of bad faith conduct.1 This history includes significant regulatory actions and legal challenges. Notably, following investigations by state insurance regulators and the U.S. Department of Labor (DOL) in the early 2000s, Unum entered into a Regulatory Settlement Agreement (RSA) with multiple states.8 This agreement mandated the reassessment of over 200,000 previously denied or terminated disability claims and required changes to Unum's claim handling procedures.8 The RSA specifically addressed concerns about unfair claim denials and aimed to implement procedures promoting fair, objective, and thorough claim evaluations.18 Despite these measures, allegations of biased practices have persisted, forming a critical backdrop against which Unum's current internal review mechanisms are often evaluated in litigation.1 More recent settlements with the DOL, primarily concerning life insurance "evidence of insurability" practices, further indicate ongoing regulatory oversight of Unum's administrative processes under the Employee Retirement Income Security Act of 1974 (ERISA).21

Alleged Profit Motive: A recurring theme in critiques of Unum's claim practices is the allegation that financial considerations unduly influence claim decisions.1 Sources cite historical practices, such as offering bonuses or incentives to claims personnel tied to claim closures or overall company profitability.1 Court documents have referenced evidence suggesting claims units operated with financial targets for claim terminations, potentially prioritizing cost savings over claim merit.5 The concept of claims departments functioning as "profit centers" has been explicitly raised in legal contexts.5 This alleged focus on financial outcomes is relevant when analyzing the potential for systemic bias within Unum's internal review structure, as the individuals conducting reviews operate within this corporate environment.19

Common Denial Tactics: Unum's internal medical reviews function within a broader claims environment where certain tactics are frequently employed to justify denials or terminations. Commonly cited reasons include assertions of insufficient medical evidence 3, reliance on the opinions of Unum's internal medical reviewers or "independent" medical examiners (IMEs) over treating physicians 1, use of surveillance to challenge claimant credibility or reported limitations 2, invocation of policy exclusions such as pre-existing conditions 4, disputes over whether the claimant meets the policy's definition of disability (often shifting from "own occupation" to "any occupation") 3, and findings that a condition is not covered.4 The internal medical review process is often central to substantiating these denial rationales.

III. Internal Medical Review Personnel: The Role of the DMO and Others

Key Personnel Identified: The provided materials identify several roles within Unum involved in the disability claim and internal medical review process:

Disability Benefits Specialist: This individual serves as the primary contact for the claimant and employer. Their responsibilities include gathering initial claim information, assessing claim complexity (potentially "fast-tracking" simpler claims like maternity leave), communicating updates, coordinating resources (like vocational specialists), and identifying claims that might transition from Short-Term Disability (STD) to Long-Term Disability (LTD).37 They also manage ongoing proof of loss requirements.38 These specialists receive ongoing training and are supported by internal nurse and vocational specialists.37
Nurse Consultants: Nurses are involved in supporting Disability Specialists 37 and participate in the medical review process.39 In some litigated cases, their qualifications to conduct specific appeal reviews have been questioned, particularly when deferring to prior reviews or lacking relevant experience.42 Their involvement can range from initial claim assessment support to participation in appeal reviews.37
On-Site Physicians (OSPs): These are physicians employed directly by Unum to review disability claims.44 Their opinions are frequently cited in denial letters and often contrast with those of the claimant's treating physicians.1
Chief Medical Officer (CMO): A senior medical leadership position within Unum. The CMO is involved in specific protocols for resolving disagreements between internal reviewers and attending physicians.45
Designated Medical Officer (DMO): This title refers to a Unum-employed, certified medical specialist holding high-level credentials in a field relevant to the claim, designated by the CMO.45 The DMO plays a key role alongside the CMO in the specific review procedure outlined for handling disagreements with attending physicians.44 (Note: The acronym "DMO" is also used in unrelated contexts to refer to Dental Maintenance Organizations 46).
Other Internal Reviewers: The materials also refer generally to "independent peer reviewers" 4, "company sponsored IMEs" 8, "internal physicians" 47, "reviewing physicians" 40, "medical reviewers" 39, "medical consultants" 48, and "claims representatives" 6 who participate in evaluating the medical aspects of disability claims.

The DMO/CMO Role in Disagreements with Attending Physicians (APs): A critical function of the CMO and DMO is outlined in specific internal guidelines (referenced as Exhibit 6 in the source material) detailing procedures when Unum's internal medical professionals disagree with a claimant's Attending Physician (AP) about their medical condition or work capacity.45

Formalized Procedure: According to these guidelines, if such a disagreement arises, Unum should generally seek an Independent Medical Examination (IME) of the claimant unless the decision is made to approve the claim, or if a specific set of conditions are met allowing a CMO/DMO review to suffice.45 This creates a documented pathway for Unum to potentially bypass an external IME.
Conditions for Bypassing IME: An IME need not be sought if all the following conditions are met and documented:

The CMO or a designated DMO (with high-level credentials in the relevant specialty) reviews the claim, focusing specifically on the points of disagreement between the AP and Unum's internal reviewers.45
The reviewing CMO or DMO conducts their own separate analysis of the disputed issues, considering all relevant information in the claim file.45
The reviewing CMO or DMO concludes with "reasonable medical certainty" that the position of Unum's internal professionals (disagreeing with the AP) is correct. This conclusion must follow a determination that the AP's opinion is "not well supported by medically acceptable clinical or laboratory diagnostic techniques" and is "inconsistent with other substantial evidence in the claim file".45

Implication: This procedure formally empowers high-level internal medical officers (CMO/DMO) to validate a denial or termination decision internally, effectively overriding an AP's opinion without an external IME, provided their analysis and conclusions meet the specified criteria. If the CMO/DMO cannot reach this conclusion of "reasonable medical certainty" supporting the internal disagreement, or if they agree with the AP, then an IME should be performed or is deemed unnecessary, respectively.45

Critiques and Potential Issues with DMO/Internal Reviewer Roles: While the CMO/DMO review process appears structured, several potential issues and critiques arise from the research materials:

Lack of Specific Expertise: Evidence suggests that Unum's internal reviewers, including OSPs and potentially DMOs, may lack specialized training or current experience in the specific medical conditions they are evaluating, such as long-COVID.44 Despite this, they may render opinions contradicting treating specialists.44 This raises significant questions about the quality, depth, and validity of the "separate analysis" required by the DMO/CMO protocol 45, as a reviewer without niche expertise may struggle to accurately assess complex conditions or nuanced specialist opinions.
Emphasis on "Objective Evidence": Internal Unum reviewers, including OSPs and DMOs, are reported to frequently demand "objective evidence" (e.g., specific test results, imaging) to substantiate a disability.44 This approach can be problematic for conditions where definitive objective markers are scarce or non-existent, such as fibromyalgia, chronic fatigue syndrome, chronic pain, and certain mental health disorders.8 Consequently, claims may be denied based on the nature of the condition lacking such evidence, rather than a holistic assessment of the claimant's functional limitations supported by clinical judgment and patient reports.27
Potential Bias: The inherent conflict of interest faced by physicians employed by the entity responsible for paying claims raises persistent concerns about objectivity.19 Given Unum's documented history of alleged biased claim administration and regulatory scrutiny 19, the neutrality of internal reviews, including those by the CMO/DMO, is frequently questioned in litigation, especially when these reviews serve to uphold a denial against treating source evidence.41 Numerous court cases involve challenges to the reasonableness of Unum's reliance on its internal medical opinions over those of treating providers.39

The interplay between the formal DMO/CMO review procedure and these potential shortcomings creates a significant vulnerability for claimants. The procedure itself relies on subjective assessments by the CMO/DMO – judging whether an AP's opinion is "well supported" or "inconsistent," and concluding with "reasonable medical certainty." If the reviewing DMO lacks deep expertise in the specific condition 44 or operates with an institutional bias favoring claim denial 19, they might readily deem a treating physician's clinical assessment "not well supported" simply because it lacks the preferred type of "objective" evidence. This allows the DMO to fulfill the procedural requirements outlined in the guidelines 45 to bypass an IME, while potentially reaching a conclusion that is substantively flawed or fails to give appropriate weight to the treating physician's perspective. In this way, the DMO/CMO review, intended perhaps as a high-level check, can function as a mechanism to internally solidify claim denials, particularly for conditions challenging to quantify objectively.

IV. Structure of Unum's Internal Medical Review: Evidence of Multi-Step Processes

Formally Acknowledged Review Layers: Unum's own documentation acknowledges at least one layer of internal review beyond the initial assessment. Materials indicate that if a claim is denied or benefits are discontinued, a second level of review by a manager or a quality assurance professional is required.37 Furthermore, it is stated that no single individual can independently accept or deny an LTD claim.37 This suggests a basic, formally recognized quality control step embedded within the process.

Evidence of Hierarchical/Sequential Reviews: Beyond the formal QA step, substantial evidence points towards a more complex, multi-step, and potentially hierarchical review process, particularly in contested claims:

Insider Account: An account attributed to someone with inside knowledge describes a "3 or 4 step hierarchy of claim review" at Unum.25 According to this account, multiple Unum doctors review claim information sequentially, with an expectation of agreement with prior internal reviews – the source asserts that "no internal UNUM physician will ever disagree with another".25 This description implies a system structured not necessarily for independent checks, but for building internal consensus, which could potentially reinforce an initial negative assessment as the file moves up the hierarchy.
Litigation Examples: Numerous court case summaries detail scenarios where Unum utilized multiple internal reviewers (often including nurses, physicians from various non-specialist fields, and vocational experts) to assess a claim sequentially. This pattern is frequently observed in cases where the final decision contradicts the opinions of the claimant's treating physicians:

In Hardy v. Unum, the termination involved initial reviews by an internist and an oncologist, plus a vocational specialist, all disagreeing with the treating physician. The appeal process involved yet another review by a different internist who reaffirmed the denial.39
In Rogers v. Unum, the denial involved multiple initial medical reviews by Unum consultants. The subsequent appeal process triggered new medical reviews by different Unum consultants and potentially others, ultimately upholding the denial based on disagreement with the attending physicians.51
In Harmon v. Unum, the initial termination relied on a Clinical Consultant Nurse, a vocational review, and an SSA denial. The appeal involved an additional review by an internal medicine physician, which supported the termination.43
In Li v. First Unum, the denial was upheld following two appeals and two independent medical examinations (potentially Unum-selected), with peer reviews from internal or contracted psychiatrists and neuropsychologists supporting the denial.48
In Crespo v. Unum, the court noted Unum relied on in-house physicians who never examined the plaintiff or communicated with her treating doctors.52
An unnamed claimant's case involved Unum relying on an internal physician (Dr. Tsourmas) who issued conflicting reports and denied the claim after stating requested MRIs were unavailable, despite them being in Unum's file.47
Another case involved termination based on reviews by one non-physician reviewer and two reviewing physicians. The appeal involved three medical reviewers upholding the denial.40

"Roundtable Reviews" and Strategic Denial Planning: The insider account also describes "roundtable reviews" as a core part of Unum's process.25 These meetings are allegedly focused not just on evaluating a claim, but on strategically planning its resolution, often involving setting an "Expected Recovery Date" (ERD) – essentially, determining when the claim will be denied or closed – and then creating a sequential "File Plan" outlining the steps needed to make that denial appear credible.25 The goal is framed as moving claims off the specialist's desk efficiently, with the denial strategy potentially being determined first, followed by actions to justify it.25 The anecdote about needing to "sanitize" claim file copies by removing the File Plan before sharing them externally underscores the potentially strategic and internal nature of this planning.25

Coordination Between STD and LTD Reviews: Unum's materials state that STD claims identified as likely to transition into LTD claims receive early attention, with LTD specialists partnering with STD specialists "well in advance".37 This early coordination is presented as ensuring continuity and allowing medical resources to be introduced promptly.37 While framed as a service benefit, this early, coordinated involvement could also facilitate the kind of strategic planning and file development described in the "roundtable review" context.25

The coexistence of a formal, acknowledged review layer 37 with allegations of an informal, hierarchical structure geared towards consensus 25 suggests a potentially complex and opaque internal system. The formal layer provides a necessary procedural safeguard and public-facing assurance of quality control. However, the hierarchical structure and alleged strategic planning sessions ("roundtables") may operate concurrently or underneath, potentially driving the process towards denial, especially for complex, long-duration, or high-value claims. The repeated sequential involvement of multiple internal reviewers, documented extensively in litigation 39, could represent the practical execution of this hierarchical approach. This sequence allows Unum to build an administrative record filled with internal opinions that align in favor of denial, creating a paper trail designed to counter external medical evidence from treating sources. This transforms the review process from one of potentially independent checks into a mechanism for internally reinforcing and justifying a predetermined outcome.

V. Legal Scrutiny of Unum's Internal Medical Reviews

ERISA Framework: The majority of employer-sponsored group disability insurance plans, including many administered or insured by Unum, fall under the purview of the Employee Retirement Income Security Act of 1974 (ERISA).1 ERISA establishes federal standards for the administration of employee benefit plans. Key requirements include fiduciary duties owed by plan administrators to act solely in the interest of participants and beneficiaries 10, and procedural mandates ensuring claimants receive specific reasons for claim denials and a "full and fair review" of any denied claim upon appeal (codified at 29 U.S.C. § 1133).42 In contrast, disability policies purchased individually, outside of an employment context, are typically governed by state contract and insurance laws.2

Standard of Review in Court: When ERISA-governed disability claim denials are challenged in federal court, the standard of judicial review is critical. If the insurance policy or plan document explicitly grants the administrator (such as Unum) discretionary authority to determine eligibility for benefits and interpret plan terms, courts typically apply a deferential "abuse of discretion" or "arbitrary and capricious" standard of review.19 Under this standard, the court does not simply decide if it would have reached a different conclusion, but rather whether the administrator's decision was reasonable and supported by substantial evidence. However, a significant factor complicates this deference: the inherent conflict of interest that exists when the entity deciding the claim is also responsible for paying the benefits.19 The Supreme Court's decision in Metropolitan Life Ins. Co. v. Glenn requires courts to consider this conflict as a factor when determining the level of deference owed.19 The weight given to this conflict may increase if there is evidence suggesting it influenced the decision, such as a history of biased claims administration.19 In some instances, particularly in states that have banned discretionary clauses (check out our blog on that), courts may apply a less deferential de novo standard, reviewing the claim determination afresh.56

Common Criticisms in Litigation: Analysis of court cases reveals recurring challenges to Unum's internal medical review processes:

Reliance on Non-Examining Reviewers ("Paper Reviews"): A frequent point of contention is Unum's heavy reliance on opinions from its internal medical staff (OSPs, DMOs, nurses) or external consultants who review the claimant's file but never perform a physical examination.4 While ERISA, as interpreted in Black & Decker Disability Plan v. Nord, does not require plan administrators to give special deference to treating physicians, courts often find Unum's reliance on paper reviews problematic, particularly when these reviews form the primary basis for rejecting the opinions of treating physicians who have the benefit of direct clinical interaction and longitudinal knowledge of the patient.52
Disregard for Treating Physician Opinions: This is arguably the most common battleground in litigation involving Unum's internal reviews. Claimants consistently allege that Unum discounts, selectively ignores, or gives inadequate weight to the opinions of their treating doctors, instead favoring the conclusions of its own internal reviewers.1 Courts have overturned Unum's decisions when the company failed to provide a reasoned explanation, supported by substantial evidence, for rejecting treating source opinions.51 Notably, the 2005 RSA specifically required Unum to give "significant weight" to attending physician opinions and document specific reasons, based on medical standards and other evidence, if rejecting them.51 Ongoing litigation suggests adherence to this standard remains contested.19
Use of Multiple Reviewers to Reinforce Denial: The pattern of sequential reviews by multiple internal personnel, often culminating in a consensus that supports denial, is frequently highlighted in lawsuits.25 Courts may view this practice critically if it appears to be a strategy to build a voluminous internal record favoring denial, rather than a series of independent, objective assessments, potentially overwhelming contrary evidence from treating sources.54
Bias and Conflict of Interest: Claimants often argue, and some courts explicitly acknowledge, that Unum's internal reviewers operate under a conflict of interest that may bias their opinions.19 This bias could stem from their employment status, potential financial incentives linked to company performance 1, or an institutional culture favoring claim closure.25 The Glenn conflict factor allows courts to reduce deference to Unum's decision based on such concerns.19 The repeated appearance of the same internal reviewers in multiple denial cases has also been noted.53
Procedural Irregularities/Lack of Full and Fair Review: Denials have been successfully challenged based on Unum's failure to comply with ERISA's procedural requirements. Examples include failing to provide the claimant with all documents relevant to the denial, not consulting with appropriately qualified medical specialists, providing inadequate explanations for the denial, or improperly introducing new reasons for denial late in the appeal process.42 A failure to meaningfully engage with treating physician evidence can be framed as contributing to a lack of a full and fair review.52
Mischaracterization of Evidence or Occupation: Courts have found Unum's decisions arbitrary when based on misinterpretations of medical records 4, misrepresentation of functional capacity testing results 54, or inaccurate classification of the claimant's job duties to support a finding that they possess residual work capacity.54

Department of Labor (DOL) Settlements: Recent settlements between the DOL and Unum (in 2023 and 2024) have primarily addressed issues related to "evidence of insurability" (EOI) requirements in group life insurance plans.21 These settlements required Unum to reform practices where it accepted premiums but later denied death benefit claims citing lack of EOI. While these specific settlements do not directly target disability claim medical review processes, they demonstrate continued federal regulatory oversight of Unum's claims administration practices under ERISA. The earlier 2004/2005 RSA, however, was directly focused on reforming disability claim handling procedures, including the evaluation of medical evidence and the weight given to treating physicians.8

Table: Key Court Cases Analyzing Unum's Internal Medical Review Processes

Presentation format:

Case Name/Citation

Key Issue(s) Related to Internal Review

Court's Key Findings/Holding Regarding Internal Review

Relevant Source ID(s)

Mundrati v. Unum (W.D. Pa. 2025)

Reliance on non-examining reviewers; Disregard of treating physician; Misclassification of occupation; Failure to order IME

Denial arbitrary & capricious; Unum relied on biased paper reviews, ignored treating specialists, misread FCE.

Hardy v. Unum (D. Minn. 2021)

Multiple reviewers used (2 MDs, 1 Voc); Disregard of treating physician (myeloma specialist); Reliance on non-specialists (internists)

Denial arbitrary & capricious; Unum improperly relied on non-specialists over treating specialist; no significant improvement shown.

Houston v. Unum (6th Cir. 2007)

Disregard of treating physician; Reliance on non-examining reviewers; Conflict of interest; Shifting rationale for denial

Denial arbitrary & capricious; Unum failed to consider treating opinions, reviewers conflicted, process violated ERISA § 1133.

Crespo v. Unum (N.D. Ill. 2003)

Reliance on internal evaluations; Failure to consult treating physicians; Disregard of specialist evidence

Denial arbitrary & capricious; Unum failed full and fair assessment by not contacting treating MDs and ignoring evidence.

Harmon v. Unum (N.D. Cal. 2023)

Reliance on internal reviewers (nurse, MD); Disregard of treating physician alleged; Conflict of interest alleged

Denial upheld; Unum's reliance on internal reviewers deemed reasonable; conflict not proven to affect decision.

Rogers v. Unum (D. Mass. 2024)

Multiple reviewers used; Disregard of treating physicians; Potential failure to follow RSA standards

Summary judgment denied; Fact dispute whether Unum properly weighed AP opinions per RSA; adequacy of consultant reviews questioned.

Li v. First Unum (S.D.N.Y. 2023)

Reliance on peer reviews (psychiatrists, neuropsychologists); Disregard of treating physician alleged

Denial upheld (arbitrary & capricious standard); Unum's reliance on comprehensive peer reviews reasonable; ERISA procedures followed.

Unknown Plaintiff v. Unum (D. Mass. 2023)

Multiple reviewers used (1 non-MD, 2 MDs); Reliance on FCE interpretation; Disregard of treating physicians alleged

Denial upheld; Reviewers reasonably relied on objective FCE data discrediting subjective reports; treating MDs lacked support for inability to work.

Merrick v. Paul Revere (9th Cir. 2007)

Biased claims investigation; Misrepresentation of policy terms

Bad faith verdict upheld; Punitive damages warranted for scheme to deny claims.

Hangarter v. Paul Revere (N.D. Cal. 2002)

Biased claims investigation; Targeting claims for termination

Bad faith finding; $5M punitive damages; Evidence of bias and plan to save money by terminating claims.

Sivalingam v. Unum (E.D. Pa. 2011)

Improper termination; Counterclaim for recovery

Unum acted arbitrarily and capriciously in terminating benefits.

Doe v. Unum (N.D. Ill. 2014)

Failure to consider occupational duties

Denial arbitrary & capricious; Unum failed to consider vocational leg of disability analysis.

Fleming v. Unum (D. Mass. 2019)

Improper use of surveillance to terminate benefits

Termination reversed; Unum overemphasized surveillance, took footage out of context, ignored decade of medical records.

Gary v. Unum (D. Or. 2016)

Reliance on medical consultants; Burden of proof on claimant

Denial upheld; Unum's decision supported by substantial evidence from medical reviews; procedural irregularities didn't amount to abuse of discretion.

Dooley v. Unum (S.D. Fla. 2023)

Termination based on improvement/activities; Reliance on internal reviewers/surveillance

Termination wrong (de novo review); Claimant met burden; Migraines still disabling despite temporary improvement/activities.

Macalou v. First Unum (S.D.N.Y. 2024)

Weighing treating/examining vs. non-examining reviewers; Reliance on nurses

Judgment for plaintiff; Treating/examining opinions more persuasive; Defendant's reliance on nurses lacking psych experience criticized.

Byrd v. Unum (S.D. Tex. 2013)

Termination based on internal medical/vocational reviews

Denial upheld (abuse of discretion); Decision supported by substantial evidence including internal reviews.

Unknown Claimant v. Unum (W.D. Ark. 2003)

Reliance on IME (context suggests Unum-selected); Evaluation of medical evidence

(Focuses on medical evidence details, implies internal review process)

Black v. Unum (D. Me. 2004)

Review of medical condition/occupation

(Focuses on initial grant, subsequent review process)

Unknown Claimant v. Unum (E.D. Pa. 2003)

Reliance on internal physician (Dr. Tsourmas) with conflicting reports; Failure to provide requested MRIs

(Case details focus on specific internal reviewer actions and procedural issues)

Unknown Plaintiff v. Unum (E.D. Tenn. date unclear)

Review under "any occupation" standard; Reliance on internal medical/vocational reviews

(Case focuses on transition to "any occupation" review and internal assessments)

The consistent legal challenges centered on Unum's reliance on internal, often non-examining, reviewers, particularly when their opinions contradict those of treating physicians, point to a fundamental friction between Unum's internal processes and ERISA's mandate for a "full and fair review." While ERISA, per Nord, does not compel administrators to defer to treating physicians, courts frequently deem Unum's internal reviews insufficient, unreasonable, or arbitrary when they fail to adequately engage with, or provide substantial evidence to refute, treating source opinions. This judicial skepticism is amplified when potential bias (due to conflict of interest or institutional history) or procedural shortcomings are evident. The sheer volume and consistency of litigation raising these specific issues suggest that merely conducting internal file reviews, even multiple sequential ones, does not automatically satisfy ERISA's substantive or procedural standards in the eyes of the judiciary if the process appears biased, cursory, or fundamentally unfair in its treatment of contrary medical evidence. The critical factor often becomes the quality, objectivity, and thoroughness of the internal review process, not merely its existence.

VI. Analysis: Documented Procedure vs. Litigated Pattern

Documented Procedures: Unum acknowledges certain structural elements of its internal review process in official documentation or guidelines. These include:

The CMO/DMO Review Protocol: Specific guidelines exist (Exhibit 6) outlining a process where a Chief Medical Officer or Designated Medical Officer can conduct a review in cases of disagreement with an Attending Physician. Under defined conditions, this internal review can substitute for an external Independent Medical Examination.45
Second-Level Review Requirement: Unum materials state that claim denials or discontinuations require a second level of review by a manager or quality assurance professional, and that no single individual can independently deny an LTD claim.37
General Claims Process: Unum describes a general process involving assigned Disability Benefit Specialists who gather information, communicate with parties, and utilize internal medical and vocational resources as needed.37

Litigated Pattern: In contrast to these documented procedures, a distinct pattern emerges from the analysis of litigation and insider accounts:

Systematic Use of Multiple Internal Reviews to Counter APs: The overwhelming theme in litigated cases is the pattern of Unum employing sequential internal reviews—often conducted by non-specialists or reviewers who have not examined the claimant—specifically to build a case against the treating physician's findings and justify denial or termination.39 It is this application of the internal review process that is frequently challenged as unfair or unreasonable.
Alleged Unwritten Practices: Descriptions of a "3-4 step hierarchy" where internal agreement is expected, and "roundtable reviews" focused on strategic denial planning and setting Expected Recovery Dates, suggest internal operational practices that are not typically disclosed in claimant-facing documents.25 These alleged practices paint a picture of an internal reality potentially geared towards claim closure rather than purely objective assessment.
Focus of Legal Challenges: Litigation against Unum concerning internal reviews tends to concentrate less on the mere existence of multiple review steps. Instead, the focus is sharply on the perceived bias (structural, financial, or institutional), the lack of thoroughness (e.g., ignoring evidence, inadequate expertise), the procedural fairness (compliance with ERISA, opportunity to respond), and the overall substantive reasonableness of how these internal reviews are conducted and ultimately weighed against compelling evidence from treating sources (See Section V analysis).

Synthesis: While Unum has formally documented procedures involving review layers like quality assurance checks or the specific CMO/DMO protocol 37, the practice of using a sequence of internal medical reviewers primarily as a means to counter treating physician opinions and build a case for denial appears more prominently as a frequently litigated pattern of behavior rather than a transparently stated objective of their official claims process. The documented procedures provide the structural framework, but extensive litigation and insider accounts suggest this framework is often implemented in a manner that systematically raises significant concerns regarding fairness, objectivity, and adherence to ERISA principles.19

The observed gap between Unum's documented procedures, which emphasize fairness and objectivity 37, and the patterns revealed through litigation and insider accounts suggests a potential divergence between the company's official stance and its operational reality. This divergence may be influenced by underlying financial pressures inherent in the insurance business or a persistent institutional culture focused on claim management and cost control.1 This disconnect forms the crux of many legal challenges, where claimants argue that the application of seemingly neutral internal review procedures results in biased outcomes that violate ERISA's standards for a full and fair review. The consistency with which these challenges arise across various jurisdictions and over time points more towards a systemic pattern of practice rather than isolated errors in claim handling.

VII. Conclusion

Summary of Findings: This analysis of Unum's internal disability claim medical review process, based on the provided materials, yields several key findings:

The role of a Designated Medical Officer (DMO), alongside the Chief Medical Officer (CMO), exists within Unum's structure. A formal process allows these high-level internal officers to review claims where internal reviewers disagree with the claimant's Attending Physician (AP). Under specific, though potentially subjective, conditions related to the perceived weakness of the AP's opinion, this DMO/CMO review can substitute for an Independent Medical Examination (IME), providing an internal pathway to validate claim denials.45
Evidence strongly indicates that Unum utilizes multi-step internal medical reviews. This includes formally acknowledged quality assurance layers 37 but, more significantly, a pattern observed in litigation and described in insider accounts involving hierarchical or sequential assessments by multiple internal personnel (doctors, nurses, vocational experts).25
This multi-step review process is a frequent subject of litigation. Legal challenges consistently criticize Unum's reliance on non-examining internal reviewers ("paper reviews"), its tendency to disregard or inadequately weigh treating physician opinions, the potential for inherent bias (structural, financial, or historical), and procedural failures under ERISA's "full and fair review" standard (See Section V analysis).
While certain review stages are documented, the specific practice of employing a sequence of internal reviews primarily to counter treating physician evidence appears more as a litigated pattern of behavior and alleged internal strategy 25 than a transparently documented component of Unum's official, claimant-facing claims philosophy.37

Implications:

Unum's internal review structure, featuring roles like the DMO and the use of sequential reviews, presents significant challenges for disability claimants. It can create an internal "echo chamber" effect, where initial negative assessments are reinforced by subsequent internal reviewers, making it difficult to overturn a denial internally.
The potential for bias within this system—stemming from the conflict of interest, alleged financial incentives, or institutional history—necessitates careful scrutiny during the administrative appeal process and any subsequent litigation.
A thorough understanding of these internal mechanisms, including the roles of different reviewers and the potential strategies employed (like "roundtable reviews" or emphasis on "objective evidence"), is crucial for claimants and their representatives to develop effective counter-arguments.

Recommendations for Claimants and Legal Practitioners: Based on the analysis of Unum's practices as revealed in the research, the following recommendations are pertinent for those challenging Unum disability claim denials:

Demand and Scrutinize the Complete Claim File: Under ERISA, claimants have the right to request their entire administrative record.41 This request should be comprehensive, seeking not only medical records and policy documents but also all internal notes, memos, emails, reviewer reports (identifying reviewers and their specialties), vocational assessments, surveillance reports, and any documentation related to internal discussions or "roundtable" meetings (though access to the latter may be contested or denied by Unum).25 Analyzing the sequence and timing of internal reviews is critical.
Challenge Internal Reviewer Qualifications and Expertise: If internal reviewers (OSPs, DMOs, nurses, consultants) lack specific, relevant expertise in the claimant's diagnosed condition(s), this should be highlighted.39 Argue that their opinions lack the necessary foundation compared to treating specialists.42
Attack Over-Reliance on "Paper Reviews": Emphasize the inherent limitations of evaluations based solely on file reviews, especially when they contradict the findings of physicians who have examined and treated the claimant over time.52 Contrast the depth of the treating relationship with the distanced nature of the internal review. If Unum did not conduct an IME, argue its necessity for a fair evaluation; if a Unum-selected IME was performed, scrutinize its objectivity and methodology.1
Aggressively Bolster Treating Physician Evidence: Do not rely solely on standard medical records or Unum's generic Attending Physician Statement forms.41 Proactively obtain detailed narrative reports from all key treating physicians that specifically address the policy's definition of disability, functional limitations (severity, frequency, duration), the clinical basis for their opinions, and directly refute any anticipated arguments from Unum's reviewers.4 Supplement with objective evidence where possible and appropriate (e.g., Functional Capacity Evaluations, neuropsychological testing), ensuring these results are interpreted by treating doctors.27 Gather supporting statements from lay witnesses (family, friends, co-workers) regarding observed limitations.4
Identify and Exploit Procedural Flaws: Meticulously review Unum's handling of the claim and appeal for any violations of ERISA regulations (29 C.F.R. § 2560.503-1) or the terms of the plan itself. This includes inadequate denial letters, failure to provide requested documents in a timely manner, ignoring submitted evidence, failing to consult appropriate specialists, or introducing new denial reasons late in the process without allowing rebuttal.42
Leverage the Conflict of Interest: Explicitly argue the MetLife v. Glenn conflict of interest factor, citing Unum's dual role as decision-maker and payor, and its documented history of regulatory scrutiny and alleged biased practices.19 Request that the court apply less deference to Unum's decision due to this conflict, particularly if specific evidence suggests bias affected the review in the claimant's case.53
Frame the Argument Around "Full and Fair Review": Ultimately, synthesize all arguments to demonstrate that Unum's entire internal review process—considering the multiple steps, the potential for bias, the handling of treating physician evidence, and any procedural errors—failed to provide the claimant with the "full and fair review" mandated by ERISA.48

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Wondering what to do if Unum denied your LTD benefits? Dorian Law PC can provide experienced guidance and evaluate your case under ERISA law. Contact us for a review of your policy terms.

***Please note that this blog provides Useful Tips, Emerging Trends, and Thoughtful Insights regarding LTD, Life, and AD&D Insurance, including summaries of reported legal decision and does not constitute legal advice. Since posting, this blog has not been updated to reflect any subsequent changes in the law. Usually the cases discussed in Case Review Corner were handled by other law firms, but if you have questions about how the developing law impacts your ERISA benefit or bad faith insurance claim, Dorian Law may be able to advise you, so please contact us.***

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Brent Dorian Brehm