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Chiropractor Wins UNUM Business Overhead Claim Following Heart Attack

The case involves a chiropractor who owned and operated his own chiropractic practice and was the primary doctor responsible for treating and consulting with patients. After suffering a heart attack, he was no longer able to continue performing his regular duties. He attempted to keep the practice operating by bringing in other doctors and maintaining his staff, but patients often wanted to be treated specifically by him. Eventually, the arrangement became unsustainable, and he was forced to close the physical office.

The chiropractor had both an individual disability insurance policy and a business overhead expense policy with Unum. While his individual disability benefits continued, a dispute developed over his business overhead expense benefits. These benefits were intended to reimburse qualifying expenses incurred in the normal operation of the business. Even after the office closed to patients, the chiropractor continued to have significant financial obligations associated with the practice.

Those expenses did not disappear simply because he stopped actively seeing patients. He remained responsible for obligations such as the office lease and utilities and still needed to maintain patient files, handle incoming calls, and assist with referring patients elsewhere. He also continued going into the office for months after closing to address these remaining business responsibilities. Nevertheless, Unum stopped paying his business overhead expense benefits.

The central dispute was not whether the chiropractor remained medically disabled but how the language of the insurance policy should be interpreted. Unum argued that business overhead benefits were no longer payable because the business was no longer “operational.” However, the policy did not define or even use “operational” as a requirement for benefits. Instead, the policy provided reimbursement for normal business expenses incurred in operating the business. Attorney Caesar Gvidia argued that the chiropractor continued operating the business for purposes of winding down its obligations even though the office was no longer actively treating patients.

The appeal focused heavily on the actual policy language and the facts surrounding the chiropractor’s ongoing expenses. Key arguments included:

• Unum relied on an “operational” requirement that was not contained or defined in the policy.
• Closing the physical practice did not immediately eliminate the chiropractor’s existing business obligations.
• Expenses such as rent, utilities, administrative responsibilities, patient-file management, and handling patient communications continued after the office stopped treating patients.
• The policy language provided coverage for qualifying expenses incurred in operating the business, and the chiropractor continued performing necessary activities associated with winding down the practice.
• Unum’s interpretation improperly added a limitation to the policy that was not supported by the actual contractual language.

Unlike many employer-sponsored disability claims, the chiropractor was not required to complete an administrative appeal before filing a lawsuit. Unum nevertheless offered an appeal as an option. Based on the policy language and the circumstances surrounding the ongoing expenses, Gvidia determined that challenging the decision through the appeal process could potentially resolve the dispute without requiring lengthy litigation.

Unum ultimately agreed with the position presented in the appeal, overturned its decision, and paid the chiropractor the additional business overhead expense benefits. The resolution was particularly important because tens of thousands of dollars in expenses were at issue, including obligations that could otherwise have left the chiropractor personally responsible for significant business debts while he was unable to work.

Unum has continued paying the chiropractor’s separate individual disability benefits, while the business overhead expense coverage is subject to its own maximum benefit amount or benefit period. The case demonstrates why business overhead expense claims can depend as much on careful interpretation of the insurance contract as on medical evidence. When an insurer relies on terminology or requirements that do not appear in the policy, reviewing the exact contractual language and how it applies to the insured’s actual business obligations can be critical to challenging the denial.