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United States District Judge Rules that Unum’s Decision to Deny Continued LTD Benefits Was Wrong because It Failed to Consider Relevant Evidence

Attorney Alex PalamaraAuthor: Attorney Alex Palamara

In an opinion issued on August 8, 2014 from the United States District – District of Massachusetts, a Federal Judge ruled that Unum’s “decision to terminated Doe’s benefits was not the product of reasonable decisionmaking and substantial evidence. It was arbitrary and capricious.” Unfortunately for the claimant/plaintiff John Doe, the Court failed to award benefits to him and instead remanded the case back to Unum, the plan administrator, for a proper review.

Facts of the Case

John Doe (a pseudonym) worked as a partner in a global accounting firm and earned $1,026,872 per year, or $85,572.67 per month. In 2004, Doe was unfortunately diagnosed with HIV. Symptoms believed to be related to his diagnosis included diarrhea and fatigue. In April 2007, Doe attempted suicide by overdose.

In addition to the depressive symptoms brought on by his diagnosis, as mentioned earlier, Doe suffered from severe diarrhea and fatigue. His diarrhea included accidents when he goes out, episodes at night preventing sleep and severe cramping experiences. His physicians’ medical records gave numerous examples of the levels of impairment Doe suffered due to his diarrhea and fatigue. His fatigue, in fact, lead him to sleep up to 14 hours per day. His doctors all agreed that due to his level of physical impairment, Doe could not work.

Shortly after his suicide attempt, Doe applied for and was ultimately approved for benefits in March of 2008. With its approval, Unum noted that the policy contained a 24 month limitation on benefits for disabilities due to mental illness. In June of 2008, Doe again attempted suicide by overdose.

24 months of benefits were paid as of October 16, 2009. On this date, the mental illness limitation kicked in and thus benefits for such a claim would no longer be payable. Likewise, after the first 24 months of benefits the “change in definition of disability” occurred and now in order to qualify for continued benefits, Doe had to prove that he was “unable to perform the duties of any gainful occupation for which (he is) reasonably fitted by education, training or experience.”

Using physician consultant reviews, Unum terminated Doe’s claim for continued long term disability benefits. Unum felt that Doe could perform the duties of his previous occupation. Doe appealed the denial and after an additional doctor reviewed the claim for Unum, Unum again concluded that Doe’s report of fatigue and diarrhea were “in excess of clinical findings and inconsistent with his activities.” After this final denial and the administrative appeals were exhausted, Doe brought an ERISA disability lawsuit.

The Court’s Rationale

In a decision issued August 8, 2014, the Court noted that Unum failed to consider relevant evidence. The Court noted that Unum’s physician consultants paid little or no attention to the documented history of diarrhea and fatigue. “Smith stated that he could find no lab etiology or clinical evidence supporting the reported fatigue. Greenhood acknowledged that he had read Kapila’s and Horst’s office notes, but did not mention fatigue in his opinion. Although he did state that Doe suffered from “occasional fecal incontinence,” he did not elaborate, dwelling instead on the etiology of Doe’s diarrhea.” Lastly, the Court noted that Silverman, another Unum consultant, devoted 6 pages of his 9 page report to merely listing the document he reviewed and only offered one conclusory paragraph to each review question.

The Court stated that Unum and its reviewers failed “to acknowledge those conditions in the first place. Despite nearly two years of notes from treating physicians detailing unremitting fatigue and fecal incontinence, Unum’s physicians chose to either cursorily reference that evidence of ignore it altogether.” The Court concluded that because Unum did not fully and reasonably consider the evidence of Doe’s physical condition, its decision to deny benefits was arbitrary and capricious.

Furthermore, the Court took issue with the Vocational Analysis performed by Unum. The Court noted that the vocational analysis is “a mere recitation of medical technology employed by various physicians… without any reasoning as to why those diagnoses would permit Doe to function in the workplace.” The Court found that “That is not enough. Nor is its flimsy recommendation that Doe should have a restroom near his office. In short, Unum did not meaningfully reconcile Doe’s medical condition with his stressful daily professional activities. Its perfunctory conclusion suggests that its review was arbitrary and capricious.”

Lastly, the Court took issue with Unum’s conclusions regarding Surveillance Video and Doe’s Recreational Travel. The Court noted that Unum and its reviewers basically ignored 5 days of video surveillance. Unum concluded that the “surveillance provides no meaningful information on which to evaluate Plaintiff’s claim for LTD benefits.” The Court noted this to be untrue. The Court noted that the 5 day surveillance showed a pattern of limited activity that should be afforded some weight as it does appear to support Doe’s claimed lifestyle as generally housebound with limited departures. The Court also took issue with Unum’s doctors’ citing Doe’s trips to visit family in New York and a trip to France as a reason why he could return to his old job. The Court noted that occasional travel is “not the same as working a demanding day job.” “Doe’s ability to ride in a car or airplane hints at his ability to perform occasional sedentary activity. But to equate occasional travel with an intense professional setting indicated the same lack of contextualized understanding of Doe’s health and work. And that failure to consider the evidence in its proper context suggests arbitrary and capricious review.”

Unfortunately for Doe, the Court’s holding that Unum’s review was arbitrary and capricious was not enough for the Court to award him benefits. The Court noted that Unum failed to consider whether Doe was able to perform the duties of “any gainful occupation”, the definition of disability in effect under the policy. Because Unum, the claims administrator, did not consider this definition, the Court remanded the case back to Unum to conduct a review as to whether Doe can perform a job that will pay him 60% of his prior earnings, or $51,343.60 per month ($616,123.22/year).

While the Court’s thought process regarding Unum’s substandard review was positive for Doe, the ultimate outcome seems unfair as Doe is now forced to again wait while Unum conducts a review under the definition of disability that Unum should have been considering this entire time. It seems unfair to penalize Doe again for the inept review Unum has continually done.

If you have been denied benefits by Unum, or any insurance provider, under similar circumstances as to what Mr. John Doe went through, please do not hesitate to speak with a Lawyer at Dell & Schaefer. Disability lawyers are available at your convenience to have a complimentary phone conference.

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