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If Unum denied or terminated your long-term disability (LTD) claim, an internal medical review (sometimes referred to as an Appeals Physician Written Review) was likely part of that decision. This is Unum’s version of a peer review report, and understanding how it’s structured can help you build a stronger response before your appeal deadline passes.
What Is Unum’s Internal Medical Review Process?
On appeal, Unum typically routes the claim file to a clinical consultant or a physician board certified in a specialty relevant to the claimant’s condition. Like other peer reviews, this is a paper review: the physician never examines the claimant and bases their conclusions solely on the records in the claim file. Appeal denials often reflect this, concluding that the file information supports the claimant’s ability to perform their regular occupation, without any in-person evaluation behind that finding.
Unum’s Single-Question Referral Format
Some insurers send their reviewing physician a long list of itemized questions. Unum’s referrals can be more streamlined. In one appeal our disability attorney handled, Unum’s entire referral to the reviewing physician consisted of a single question: whether the available medical and file information supports restrictions and limitations that preclude the claimant from performing the occupational demands of the job, as of a specific date, with an explanation.
A single, open-ended question can cut both ways. It gives the reviewer less of a rigid checklist to work through, but it also gives the reviewer considerable latitude to reach a broad conclusion without addressing each piece of contrary evidence individually. That makes it especially important to identify exactly what evidence the reviewer relied on, and what they didn’t address, when you respond.
How Much Time Does Unum Give You to Respond?
Once the medical review is complete, Unum generally gives claimants a window to respond before finalizing its decision. That window can be short. In one appeal the firm handled, Unum gave the claimant just 15 days to respond to new evidence generated during the appeal. If you need more time to obtain a statement from your treating physician or gather additional records, request an extension from Unum in writing as early as possible.
Is Unum’s Reviewing Physician Actually Independent?
Unum selects and pays the clinical consultants and physicians who perform these reviews, the same arrangement that raises questions about impartiality across the industry. Unum has a long history of facing scrutiny, including bad-faith litigation, over how it handles claims. A reviewer whose conclusions consistently favor Unum’s position isn’t likely to lose future referral work.
This matters because a single broad conclusion, such as a statement that the file doesn’t support restrictions as of a given date, can be difficult to challenge unless you break it down and identify precisely which evidence the reviewer seems to have overlooked or discounted.
Building a Response to Unum’s Review
If Unum’s denial or appeal decision relied on a peer review report, take these steps before your response deadline:
- Ask your treating physician to respond point by point. Because Unum’s question can be broad, a general letter reaffirming the diagnosis is less effective than a response that addresses the reviewer’s stated conclusion directly.
- Identify what the reviewer didn’t address. If the review doesn’t mention specific test results, functional evaluations, or treatment notes in your file, point that out explicitly.
- Tie your evidence to the occupational demands at issue. Since Unum’s question is framed around whether you can perform the demands of your occupation, evidence that speaks directly to those specific demands carries more weight than a general statement about your diagnosis.
- Submit everything before the deadline, or request an extension in writing. Given how short Unum’s response windows can be, don’t wait until the last few days to start gathering evidence.
How the Ortiz Law Firm Can Help with an Unum LTD Appeal
Nick Ortiz and the team at Ortiz Law Firm handle Unum LTD denials and appeals and understand how the company’s internal medical review process fits into its broader approach to claims. Unum’s single, broadly worded referral questions can make it harder to know exactly what to rebut, but a targeted response built around the reviewer’s actual conclusion can make the difference on appeal.
If Unum denied your claim based on an unfavorable medical review, don’t assume the report is the final word. Ortiz Law Firm represents claimants nationwide and can help you build an appeal that addresses the review directly. Contact Ortiz Law Firm online or call (888) 321-8131 for a free case evaluation.
Frequently Asked Questions
How is Unum’s internal medical review process different from other insurers’ peer reviews?
Some insurers send reviewing physicians a detailed list of itemized questions tied to specific diagnoses or date ranges. Unum’s referral can instead consist of a single, broadly worded question asking whether the file supports restrictions as of a given date. That format gives the reviewer more discretion, which makes it important to pin down exactly what evidence they relied on.
What if Unum’s review says the file doesn’t support my restrictions?
Don’t treat a broad conclusion as unchallengeable. Ask your treating physician to respond directly to the reviewer’s statement, and identify any specific test results, functional evaluations, or treatment records the reviewer’s conclusion doesn’t appear to address. A targeted rebuttal is generally more effective than a general restatement of your diagnosis.
How long do I have to respond to Unum medical reviews?
The window can be short and varies by claim. If you need more time to gather a response from your treating physician or additional records, request an extension from Unum in writing as soon as you receive the review, rather than waiting until close to the deadline.
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📰 This article is sourced from a trusted insurance industry publication. Legacy Life Insurance Group shares this for informational purposes only. Always consult a licensed advisor for personalized guidance.