Can UNUM Deny LTD Benefits When Plaintiff Proves Eligibility by a Preponderance of the Evidence?

In the case of Paul Luu v. First Unum Life Insurance Company of America (Unum), Plaintiff had been employed by MUFG Union Bank (Union) for approximately 25 years when, on February 12, 2015, he was given a negative performance review and put on notice that he could be terminated.

Plaintiff stated that on that date, “it all came together… mentally and physically, he could not do it anymore. He just crashed.” The events of the day forced him to call in sick the following day, a Friday, and seek medical treatment the following Monday. His physician put him on temporary disability for two weeks, and he never returned to work.

Medical treatment

Plaintiff received medical, psychological, and chiropractic care. His main treating physician was Dr. Hao Thai, a geriatric and pain management specialist, diagnosed Plaintiff with cervical sprain/strain, lumbar sprain/strain, shoulder and wrist problems, anxiety, insomnia, depression, myalgia & myositis, lumbar radiculopathy, rotator cuff syndrome, muscle spasms, headaches, and acute stress reaction.

Dr. Thai recommended that Plaintiff be out of the office for two weeks and referred him to counseling for thoughts of suicide. Dr. Thai also prescribed Ativan and Motrin.

In February 2015, Plaintiff filed a claim for short term disability (STD) benefits with his disability insurance company, Unum. His claim was approved for 180 days. Meanwhile, Plaintiff sought treatment from Dr. Flores, a psychologist, in relationship to his workers’ compensation claim. Flores determined that Plaintiff’s psychological problems were due to the stress he had faced at work, and for being falsely accused of some mismanagement of funds.

Dr. Thai again saw Plaintiff for his neck and lower back pain, which Plaintiff said had bothered him for years, but he continued to work and tolerate the pain. He took over-the-counter pain medication and did not want to miss work since he was involved in multiple time-consuming projects.

In March 2015, Dr. Thai ordered several MRI studies which verified Plaintiff had cervical and lumbar disc problems, rotator cuff tears and carpal tunnel syndrome. Nerve conduction studies determined that Plaintiff had higher than average measurements and indicated there was irritation on seven nerves suggesting chronicity on three different nerves.

In May 2016, chiropractor Rolando A. Martinez conducted a functional capacity evaluation (FCE). Dr. Martinez noted that Plaintiff could return to work with certain restrictions, including limited keyboard time and the ability to sit and stand as necessary.

Plaintiff was seen in July 2015 for a comprehensive orthopedic examination by Dr. Matos, an orthopedic surgeon. Dr. Matos treated Plaintiff for several months, referred him to chiropractic treatment, and recommended surgery. Plaintiff was also seen by a neurosurgeon, Dr. Mesiwala, who also recommended surgery since his cervical spine problems had worsened. Meanwhile, Plaintiff also underwent physical therapy for his shoulder problems.

Claim for long term disability benefits

On June 29, 2015, Plaintiff submitted a claim for long-term disability (LTD) benefits, asserting he was unable to perform the duties of his regular occupation. Union conducted an occupational analysis and determined that “Software Engineer” was the most consistent job description in the national economy with Plaintiff’s regular occupation.

Unum had its onsite physicians review Plaintiff medical records. A family medicine doctor reviewed the records of Plaintiff’s orthopedist and concluded that all restrictions for all of Plaintiff’s problems were “inconsistent with the medical evidence.” Similarly, all other reviewers determined the medical evidence did not support a finding of disability and concluded that Plaintiff could perform the duties of his regular occupation.

On November 5, 2015, Unum denied Plaintiff’s claim for LTD benefits and informed him of his right to appeal.

Administrative appeal denied

On January 27, 2016, Plaintiff filed his administrative appeal. He submitted evidence of his orthopedic problems, an updated Attending Physician Statement from Dr. Flores and two new medical reports from Dr. Matos.

Unum again had its medical professionals conduct a paper review. Unum denied the appeal on March 18, 2016. Having exhausted his administrative remedies, Plaintiff filed an ERISA lawsuit in the United States District Court for the Central District of California.

District Court decision

After conducting de novo review, the Court ordered Unum to pay Plaintiff past due LTD benefits from August 12, 2015 through August 12, 2017, plus interest, the time for which Plaintiff was disabled from performing the duties of his own occupation. The Court remanded to Unum to determine whether after that time, Plaintiff was disabled and “unable to perform the duties of any occupation for which he is reasonably fitted by education training or experience.”

De Novo Standard of Review

The Court clarified that “de novo review” is a “misleading phrase.” The Court would not be reviewing the administrator’s decision for abuse of discretion, or to determine if denying benefits was arbitrary or capricious. Instead, the Court would review the entire administrative record and determine whether Plaintiff proved beyond a preponderance of the evidence that he was entitled to disability benefits.

The Court concluded that Plaintiff met his burden and showed he “is disabled under the terms of the Plan. Therefore, for the reasons explained below, Unum’s claim denial is overturned.”

Plaintiff Was Covered by the Plan and Eligible to Receive Benefits

Unum argued in the District Court that Plaintiff quit work due to fear of being terminated and that he was not actively employed at the time of his disability and not covered by the plan. Therefore, he was not eligible for benefits even if he was disabled.

The Court disagreed. Plaintiff was eligible for benefits while he was actively employed by Union Bank. The Plan was silent as to the effect of sick days on eligibility. The Court found that the medical evidence showed that he had been suffering for years from his orthopedic issues, including his neck pain and lower back pain and had not taken time off work due to his work on multiple projects. Plaintiff also complained to his psychologist of a history of confrontations and problems with his supervisor dating back to 2010.

On his last day of work, Plaintiff reported his symptoms to his supervisor. This was on a Thursday, and he sought treatment the following Monday when he was placed on temporary disability. He was still employed at the time he filed his claim for STD benefits. Therefore, he was eligible for benefits under the terms of the Plan.

Court Ordered Unum to Pay LTD Benefits to Plaintiff During Time he was Unable to Perform the Duties of his Own Occupation

The Court found the conclusions of the “six on-site Unum physicians” who found Plaintiff not disabled had not cited correct information for their conclusionary statements. For example, one reviewer said there had been no electroconduction studies when in fact, there had been.

The Court finally concluded that after thoroughly reviewing the administrative file, “including the opinion of Luu’s treating physicians, Unum’s reviewing physicians, and the Functional Capacity Evaluation, the Court believes that Luu has proven he was both physically and mentally ‘functionally disabled’ during the relevant time period… thus, the fact that Unum’s benefits for mental illness are limited to 24 months is irrelevant given that Luu was still physically disabled during this period.”

This case was not handled by our office, but we have helped clients who have had similar issues. If you have questions about this case, or any questions about your disability claim, either for STD or LTD benefits, contact one of our disability attorneys at Dell & Schaefer for a free consultation.

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