Our Bay Area clients often ask us whether they need a definitive diagnosis in order to receive long-term disability benefits under their employer’s ERISA-governed group disability plan. For some, disabling symptoms might take a while to diagnosis. Although the terms of a disability policy will vary by employer, most policies do not specifically require a diagnosis. In fact, most policies will just require that a disability plan participant be unable to perform his or her job duties as a result of a physical or mental illness. Where the lack of a definitive diagnosis presents a problem is when a disability policy also requires that a participant receive appropriate care and treatment for the disabling condition. Receiving appropriate care and treatment is difficult if your doctors do not have a clear understanding of what ails you.
The interplay between a diagnosis and disability is illustrated in a recent court decision in the matter of Bunger v. Unum Life Insurance Company of America, No. 2:15-CV-01050-RAJ, out of the Western District of Washington. In this case, Plaintiff Bunger challenged a denial of both short-term disability and long-term disability benefits for his disability caused by Chronic Fatigue Syndrome, Lyme disease, or an unspecified illness which causes extreme fatigue and inability to concentrate. Unum argued that Bunger has no properly diagnosed conditions, and has not shown that he is unable to perform his job functions.
The court noted that Unum appears to conflate the issue of whether Bunger is sick with the issue of whether Bunger has been properly diagnosed. Just because Bunger may not have been correctly diagnosed does not mean he is not sick. Bunger claimed to not be able to focus for more than a few minutes at a time, making it impossible to perform varied and complex work tasks. He also claimed to not be able to cook, clean, or care for his children. Unum did not suggest that Bunger’s complaints are untrue, just that those complaints have not been properly tested, diagnosed or treated. The court believed that the proper response would have been for Unum to inform Plaintiff of the necessary testing rather than simply deny his claim. The court sent Bunger’s claim back to Unum so that the record could be fully developed.
If you are suffering from an undiagnosed medical condition, that should not impair your ability to get the benefits you need in order to stay focused on getting better. A knowledgeable ERISA attorney can prevent the failure of medical science from negatively impacting your long-term disability benefits. At Kantor & Kantor LLP, we help our clients navigate the difficult terrain of a long-term disability claim. Our firm represents individuals from all over the Bay Area – including San Francisco, Oakland, and San Jose – in their ERISA benefit claims.