Wednesday, December 01, 2004

No Conflict In Their Interest

The case of Stup v. UNUM Life Insurance Co. illustrates that (i) insurance companies are as susceptible to the lures of conflict of interest as anyone else, (ii) insurers apparently have no problem buying "expert" opinions that are tailored to fit the conclusions they desire, and (iii) insurers will often go to great length to deny benefits, putting costly roadblocks in the path of insureds who are entitled to coverage.

Wanda Stup suffers from lupus, fibromyalgia, Graves disease, or hyperthyroidism, degenerative disc disease, and eye problems. Without going into detail here, her various maladies are serious, painful, chronic, and have been well-documented for a substantial period of time. The Board Certified rheumatologist who had been her treating physician for several years wrote a detailed opinion letter that concluded that she could not perform even sedentary work.

Stup had a long-term disability insurance policy through her employer. Under the terms of the policy, her benefits were limited to two years if she could not "perform each of the material duties of any gainful occupation for which [s]he is reasonably fitted by training, education or experience." After two years, UNUM, the insurer, denied Stup further benefits declaring that "[s]ince the definition of disability now applies to ‘any occupation’ we feel you could return to work in a sedentary occupation."

Stup challenged the denial of benefits. As part of the appeal process she was required to undergo a "Functional Capacity Evaluation" or FCE. Again without going into details, the description of her efforts during the FCE make for painful reading. They must have been equally painful to watch, since the physical therapist conducting the FCE halted the exam after only 2 1/2 hours due to Stup's physical exhaustion. The physical therapist concluded that "it would not be prudent to make recommendations regarding specific job duties that [Stup] can or cannot perform due to a lack of consistent and true information [from the FCE]."

Based on the FCE, UNUM continued to deny Stup benefits. She filed suit in the U.S. District Court for the District of Maryland. UNUM opposed her claim, contending that its denial of benefits was based upon "substantial evidence." Neither the District Court nor the Fourth Circuit had any great difficulty concluding that not only was there no substantial evidence for the claim, but that its denial of the claim was not "the product of a principled reasoning process." The Fourth Circuit (a notoriously pro-business court) essentially smashed UNUM's defenses into pieces.

This case demonstrates a theme that I've already touched on in different ways in previous posts and which I intend to come back to regularly. The relationship between employor and employee (actually, in this case, insurer and insured) is asymetrical, with the employer holding a good deal of leverage in any dispute or negotiation. In this case, for instance, Stup was out of work due to her disability, a disability so severe that she could not even due all of her own housework. For four years, she was without income. She faced an insurance company with a strong incentive to deny benefits (every claim denied discourages other potential claimants from making claims in the first instance) and which had created an institutional machine designed to achieve that goal. The opinion doesn't reveal whether UNUM had ever made an offer to settle the claim, but such an offer, even a niggardly one, if it were made, would have been tempting to Stup given the financial straits she was in. And, of course, UNUM had a small platoon of medical professionals willing to issue an opinion favorable to UNUM despite a mountain of facts to the contrary. (If you don't believe me, read the Court's comments in footnote 7 on page 14 of the slip opinion.)

The lesson of this case should, but probably won't, be instructive to the public in the current dispute over so-called tort reform. Insurance companies win when they don't pay claims. While some modifications of the tort system may be justified (so that, for instance, in cases such as presented by Stup, her attorneys' fees are paid and she receives recompense for the time value of the benefits that were denied her), but that's not what proponents of tort reform want. They simply want to rig the game in their favor, systemically limiting or prohibiting claims. If you don't believe me, re-read the Stup opinion.

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