After paying for 13 years Unum Denies Disability Benefits to Woman with Lyme Disease and Endometriosis

In Stephanie Dorris v. Unum Life Insurance Company of America (Unum), Plaintiff was President of Beans Plus, Inc. when about 20 years ago she became unable to perform the duties of her own occupation due to her suffering from endometriosis. She was covered under her employer’s long term disability insurance benefit plan through Unum.

Under the terms of the policy. LTD benefits would be paid for two years if the insured person could show the inability to perform “each of the duties of her own occupation” due to an injury or sickness. After two years, the definition of disability changed and in order to receive LTD benefits, the employee needed to prove either: 1) She was unable to perform the material duties of any occupation for which she was “reasonably fitted by training, education, or experience;” or 2) She is performing at least one of the material duties of her regular occupation, or another occupation on a part-time or full-time basis and receiving at least 20 percent less than her previous full-time pre-disability income “due to that same injury or sickness.”

Plaintiff suffered for years with endometriosis pain. In 2002, the pain became so severe she quit work and Unum began paying her LTD benefits. In 2007, the Social Security Administration determined she was disabled from working at any occupation and began paying her disability benefits.

Through the years, Unum periodically reviewed her case. In 2013, its review of her medical records revealed that the endometriosis had improved. Her new primary diagnosis was Lyme disease.

Unum began its 2015 review with a phone call to Plaintiff. She reported she was feeling better. She was doing volunteer work and playing nine holes of golf at a time on a weekly basis. The volunteered as a docent at the local zoo and was treasurer of a non-profit organization. The appellate opinion notes that Unum did some “sleuthing” and discovered she was also active in a protest group against a hospital.

Plaintiff’s treating physician, Dr. Steven Harris, provided Unum with his opinion that she could only perform sedentary work for four hours a day and would need to have frequent breaks and absences. In a follow-up with Dr. Harris, he reported that Plaintiff could not work at all due to “extreme fatigue” and “major memory and cognitive issues.” Her other treating physicians deferred to Dr. Harris.

Unum had two consulting physicians review the medical records to determine if Plaintiff could return to her sedentary occupation as a corporation president. Both questioned the diagnosis of Lyme disease and determined she could perform the duties of her regular occupation.

Based on the opinions of the reviewing physicians, Unum terminated Plaintiff’s LTD benefits. She filed an administrative appeal and supplemented the record with an update of Dr. Harris’ opinion, her own explanation of the limited extent of her volunteer activity and fellow volunteers who supported “her story.”

Unum had a third consultant review the records who also determined that she did not suffer from Lyme disease and could return to her regular occupation. Unum’s vocational consultant updated Plaintiff’s job description as one that required more than 40 hours of work a week and required occasional travel. The consulting physician still opined she could do that job.

Unum requested Plaintiff undergo an independent medical examination at its expense. She refused and shortly after her refusal, Unum denied her appeal and concluded she could return to her job as a corporation president. She then filed an ERISA lawsuit in the United States District Court for the Southern District of Illinois.

District Court Held Plaintiff Failed to Sustain her Burden of Proof

Early in the proceedings, Plaintiff’s disability attorney requested to depose the vocational consultant and the reviewing physicians who worked for Unum as well as for her own treating physician, Dr. Harris. The reason for the request was for “clarification” of their opinions. The Magistrate Judge denied the request, but left it open for her to obtain discovery consistent with Rule 26. She did not object to the Magistrate’s ruling nor did she request further discovery.

Plaintiff argued that there was a lack of evidence in the record concerning what jobs Unum thought she was reasonably fitted for, or the material duties of any other occupation. But, the District Court pointed out, the burden of proof was on the Plaintiff to provide her own evidence of why she was disabled from working at any other occupation.

After reviewing the administrative record, the District Court held that Plaintiff had proven that she could not perform the duties of a corporation president but determined she had failed to show she was disabled from “the other two prongs of the plan definition.”

The District Court specifically noted that Plaintiff did not meet her burden of proof and had missed several opportunities to do so. For example, Plaintiff:

The Court entered judgment for Unum. Plaintiff then filed an appeal with the United States Court of Appeals for the Seventh Circuit.

Seventh Circuit Affirms the District Court Decision Based on its Review for “Clear Error

Unum accepted the District Court finding that Plaintiff was disabled from working at her regular occupation. The issue the Circuit Court (Court) focused on was whether Plaintiff had met her burden of proof on either of the other two prongs of the disability policy that would allow her to collect LTD benefits.

The Court noted that the District Court was not charged with reviewing Unum’s decision for abuse of discretion but was charged with reviewing the record to determine if Plaintiff was entitled “to benefits. In addressing that question in the District Court, the Plaintiff “carried the burden of proof.”

On appeal, the Court would only reverse the decision of the District Court if it found the decision was a clear error. “On clear-error review, we will affirm that finding if it is ‘plausible in light of the record viewed in its entirety.'”

The Court noted that precedent allows “the parties to introduce extra-record evidence and seek appropriate discovery.” The Plaintiff could have sought discovery to patch any “gaps in the record that cut against her claim” before the District Court reached its final decision. She did not do so.

The Court concluded that “The district court was presented with an underdeveloped administrative record. From this record, it concluded that [Plaintiff] failed to carry her burden, as the plaintiff, to demonstrate she was entitled to benefits. We see no clear error in that finding or abuse of discretion in the limitation of its review to the administrative record. We therefore affirm the judgment.”

This case was not handled by our office, but we believe it can be helpful to those who are appealing the termination of their long-term disability benefits. If you have a question about this case, or any question about your disability claim, whether for long-term or short-term benefits, call a disability insurance attorney at our disability insurance law firm of Dell & Schaefer for a free consultation.

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Dell & Schaefer Client Reviews   *****

Emily H. (Massachusetts)

Rachel and team were professional, knowledgeable and competent in helping me with my disability insurance claim denial. I would not have been able to do this work myself successfully.  I had an illness best known as Chronic Lyme (I have more issues than that but that’s what I understood my diagnosis to be at the time of claim denial). This is a complex illness that is plagued with faulty testing, delayed diagnosis, inconsistent prognosis/ treatment outcomes, and vague (deniable) symptoms.

Advances in the disease’s treatment have stalled for decades due to financial & reputational conflicts of interest that exist across the healthcare/ insurance / government industries. It is a major thing to go against, and a very complex & constantly evolving issue, and Rachel was very familiar with all the chronic Lyme ‘inside baseball.’ Not many people want to get involved with anything Chronic Lyme-related if they have a choice. Finding an attorney that has expertise in this area is a rare find, and I can attest to the fact that Rachel meets this hard-to-find criteria and delivered results well beyond what I could have achieved without her.

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