Court agrees with Unum’s denial of long term disability benefits to man suffering with rheumatoid arthritis and osteoarthritis (Part II)

Yet, another case that has appeared in District Court demonstrates the challenge long-term disability attorneys face when representing a client when the Court uses the arbitrary and capricious standard to review the decision of a long-term disability plan. Even though the case we are going to consider involves a claim administrator with both discretion to determine whether the claimant qualified for benefits and an inherent conflict of interest because the claim administrator also issued the benefit plan, the arbitrary and capricious standard only shifts the burden of proving that the decision was reasonable to the plan administrator.

Paul Blackwell had been the Vice president of Quality Management at Beverly Enterprises, Inc. when he stopped working on December 18, 2001 and filed for long-term disability benefits from the Unum policy he participated in at Beverly. He claimed that he could no longer fulfill the extensive travel requirements of his job, which including providing quality management at Beverly’s over 550 facilities across the United States. For further background history of this case against Unum see Part I: Unum relies on independent medical exam as basis for denying long-term disability benefits.

Disability insurance claimant’s medical evidence plays pivotal role in Court decision.

Blackwell had begun experiencing severe pain and stiffness in his joints and back in 2000. He began seeing a doctor in May of that year. His doctor ordered a CT and an MRI of his lumbar spine to identify the source of his pain. His doctor ordered a prescription of Vioxx to relieve the osteoarthritis the scans identified. Subsequent visits to additional physicians built a case that rheumatoid arthritis was causing Blackwell’s pain and stiffness. When he applied for long-term disability benefit on Feburary 6, 2002, Blackwell had what he considered a well-confirmed case for disabling arthritis.

Unum disagreed. After asking an RN to perform an in-house clinical review of all of the medical records it has requested from Blackwell’s treating physicians, Unum decided that more information would be needed in order to evaluate whether Blackwell’s arthritis actually limited his ability to work as a vice president of quality management.

The disability insurance plan sent Blackwell’s file to Unum’s Vice-president and Medical Director for a full medical review. After reviewing the file, Dr. Caruthers recommended an independent medical examination (IME) and a functional capacity evaluation (FCE) to guarantee a full and fair review of Blackwell’s claim.

When the FCE came back showing that Blackwell retained the ability to handle medium level low lifts and mid lifts as well as light lifting at a light level it became questionable as to whether the limitations imposed by his physician were realistic. The FCE also found that Blackwell could walk, kneel, reach to the immediate right or left, finger, push or pull a cart weighing 40 lbs., and carry 20 lbs. frequently. He could stoop, crouch, handle, climb stairs, sit and stand on an occasional basis. The only question raised by the FCE was Blackwell’s ability to sustain any of these activities over a sustained period of time. It was observed that Blackwell needed to change his sitting position every 2 or 3 minutes.

The IME likewise failed to reveal any severe limitations impeding Blackwell’s ability to perform the primary functions of his position. After a 62 minute physical exam, the doctor found only mild symptoms of rheumatoid arthritis – no significant joint mobility issues, no difficulty writing or filling out intake forms. The IME report made it clear that the doctor had considered whether Blackwell qualified for temporary disability. He concluded that the medical evidence just didn’t support RA severe enough to warrant it.

Unum went on to order another Medical File Review from Dr. Caruthers. Enhanced by the IME and FCE, Dr. Caruthers still found that the medical record failed to support Blackwell’s disability. Based on this conclusion, Unum denied Blackwell’s claim on July 26, 2002.

Blackwell appealed the denial on November 1, 2002. After sending Blackwell’s file for a Full Clinical Review and then another Medical Review, Unum had upheld its decision on December 16, 2002. Blackwell’s disability attorney filed a lawsuit against Unum.

Unum must prove it reached a reasonable decision.

Despite the conflict of interest the Court needed to consider when applying the arbitrary and capricious standard, Blackwell’s disability attorney can only rely on the medical records in Blackwell’s administrative record. Would the Court find that Unum had met its burden to prove that its interpretation of the policy’s terms had been reasonable and that it had applied those terms based upon substantial evidence?

Unum points to the thoroughness used to review Blackwell’s claim.

When the Court reviewed the administrative record, it was readily apparent that Unum had taken the time to make sure it handled Blackwell’s claim properly. First, Unum reviewed the claim as sent by Blackwell. When the evidence failed to support the claim sufficiently, Unum requested medical records from Blackwell’s health care providers. Only then did Unum conduct an in-house clinical review. When a question arose, the file was sent to the top in-house physician. He sent his report to Blackwell’s primary care physician for review and input. He also recommended an FCE and IME, which was done. Only after this information was available and the final medical review confirmed the conclusion that Blackwell did not meet the specifications of the policy for receiving benefits, did Unum send Blackwell a letter denying his disability claim.

Disability attorney claims the process was a sham.

According to Blackwell’s disability attorney, Unum ignored evidence selectively. He claimed that Unum ignored restrictions recommended by one of his treating physicians because “the patient” had assisted with the filling out of the form. The doctor has signed the form, placing his stamp of approval upon the restrictions. A later report from the same doctor revised the limitations slightly, but still indicated that lifting and repetitive hand motions were to be avoided. The same doctor also stated that osteoarthritis and rheumatoid arthritis were his diagnosis.

The disability insurance attorney also pointed to the fact that Blackwell had been forced to go to a podiatrist for ingrown toenails because his arthritis made it impossible to care for his own feet properly. He claimed Unum had ignored this evidence.

Unum had failed to credit the opinion of a rheumatologist that Blackwell saw, the disability attorney claimed. And he contended that the FCE that Unum claimed proved Blackwell was not disabled, actually proved the opposite.

Court finds administrative record contradicts disability attorney’s claims.

Every point raised by the disability attorney had been discussed in the administrative record. When it seemed that the restrictions were excessive, the file was sent to someone with more expertise. Test results were discussed in the Medical File Review. When it appeared that the patient had filled out the Attending Physician Statement, the matter was pursued with the physician. The observations made by Blackwell’s rheumatologist were carefully considered. The visit to the podiatrist was also noted.

Unum had provided the company performing the FCE with a list of the restrictions and limitations recommended in the attending physician’s statement. The disability insurance plan also provided the FCE, all the medical records Unum had obtained, the official job description and Blackwell’s own description of the physical requirements of the job to the physician conducting the independent medical examination. This doctor’s report demonstrated that he had carefully considered all this information before he reached his conclusion that Blackwell was currently able to fulfill the substantial duties of his occupation as a vice president of quality management. He noted Blackwell’s own reported improvement with a change in his arthritis medication. While he agreed that Blackwell did suffer from degenerative arthritis, the findings of his own exam and the test results in the medical record failed to support disability from performing the job as described.

Court affirms Unum’s decision.

Under the arbitrary and capricious standard, Unum had met the ERISA requirement to conduct a full and fair review before the disability plan denied Blackwell’s long-term disability claim. Unum had observed the requirement to give weight to the opinion of Blackwell’s treating physicians. Under Tenth Circuit Law, Unum needed only to support its decision with sufficient facts to demonstrate its decision had not been arbitrary or capricious.

The denial didn’t need to be the best decision or even the only possible decision. Unum only needed to prove that it was a logical decision in light of the facts. The Court found that Unum had succeeded in establishing that its decision was not arbitrary or capricious. The Court affirmed Unum’s denial of long-term disability benefits based on substantial evidence. The arbitrary and capricious standard is skewed in favor of the insurance companies, therefore it is essential to have your medical condition well documented by your treating physicians.

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There are 2 comments

  • Lisa,

    This case is an unfortunate reminder that although some objective test may show the presence of a medical condition, that presence alone is not enough to establish disability. There must be a causal connection between the condition and documented restrictions and limitations in order to provide disability. In the case at hand, the functional testing indicated a level of physical ability that reflected the requisite physical ability to work.

    Stephen JessupJan 8, 2014  #2

  • I have severe RA and have one question what about the findings from the blood work? I may appear to look normal, be able to push a shopping cart, walk slowly up down stairs, once a day lift or push 10 or more pounds, but that’s it. Nothing continuous. I don’t want to be judged by what it appears I am able to do for an hour a day. I am here to tell you that will be the only hour of the day I would be working. RA is very painful and every minute of movement that I engage in I suffer 10 minutes of after effect. My blood work has changed minimally over six months showing major inflammation throughout my body. How could you miss introducing the blood work? In my opinion that is the story behind the curtains. How can anyone argue with that?

    Lisa D.Jan 7, 2014  #1