Court Rules Plaintiff’s Medical Records Was Replete With Evidence Supporting Claim of MS & Was Not A Pre-Existing Condition

Background

In Bayer v. Unum Life Insurance Company of America, C.A. No. 18-9702 (E.D. LA 2020), Plaintiff began working as a senior property manager for Sealy Operating III, Inc., in September 2014. According to Sealy’s written job description, Plaintiff’s job duties included maintaining properties in good order and condition by contracting and scheduling necessary repairs and maintenance, conducting walk-throughs of buildings to ensure strict standards for maintenance and cleanliness, and researching vendors and collect bids from contractors. Plaintiff was also responsible for compiling budgets and other financial reports.

After developing neurological symptoms of right hand and right body numbness and dragging of her right foot, Plaintiff underwent an MRI in January 2015. The January 2015 MRI showed “a few nonspecific white matter changes.” Due to her new neurological symptoms and the white matter lesion in the January 2015, Plaintiff was referred to a Board Certified Neurologist specializing in Multiple Sclerosis (“MS”), who also served as the Program Director of a nationally recognized MS treatment center. Following several visits, in May 2015 it was determined that Plaintiff met the criteria for clinically definite MS.

Unum’s Rationale for LTD Denial

In January 2016 Plaintiff submitted her claim for LTD benefits under Sealy’s Group Long Term Disability Policy administered and funded by Unum. In June 2016 Unum denied Plaintiff’s claim for LTD benefits because Unum concluded that Plaintiff’s MS was an excluded “pre-existing condition” under the terms of Unum’s Long-term Policy and Sealy’s prior insurance carrier’s plan (“the Prudential Plan”). Pursuant to the Long-term Policy, disabilities due to “pre-existing conditions” are not covered. The Long-term Policy defines a “pre-existing condition” as existing if a person: (1) “received medical treatment, consultation, care or services including diagnostic measures, or took prescribed drugs or medicines in the 3 months just prior to [his/her] effective date of coverage” and (2) “[t]he disability begins in the first 12 months after [his/her] effective date of coverage.” The Unum Long-term Policy took effect on April 1, 2015 and Plaintiff’s date of disability was September 25, 2015, which is within the first 12 months of the effective date of the Long-term Policy. Therefore, if Plaintiff received medical treatment, consultation, care or services, including diagnostic measures, or took prescribed drugs or medications between January 1, 2015 and March 31, 2015, then the pre-existing condition exclusion would apply, and Plaintiff would not be entitled to LTD benefits under the Long-term Policy.

Unum’s Long-term Policy also contains a “continuing coverage” clause, which states that Unum will pay long-term disability benefits for what would be considered a pre-existing condition under the Long-term Policy if it would not be considered a pre-existing condition under the employer’s prior insurance carrier’s definition (here, the Prudential Plan). Under the Prudential Plan, a claimant has a pre-existing condition if the circumstances listed in numbers 1 and 2 below are both met: 

1. (a) [The person] received medical treatment, consultation, care or services, including diagnostic measures, or took prescribed drugs or medicines, or followed treatment recommendation in the 3 months just prior to [his/her] effective date of coverage; or

(b) [The person] had symptoms for which an ordinarily prudent person would have consulted a health care provider in the 3 months just prior to [his/her] effective date of coverage. 

2. [The person’s] disability begins within 12 months of the date [his/her] coverage under the plan becomes effective. 

Based on Plaintiff’s date of hire – i.e., September 2014 – her effective date of coverage under Sealy’s Prudential Plan was December 1, 2014. Because Plaintiff’s date of disability of September 25, 2015 is within 12 months of the date that her coverage became effective under the Prudential Plan, if Plaintiff received medical treatment, consultation, care or services, or took prescribed drugs or medicines, or followed treatment recommendation between September 1, 2014 and November 30, 2014, or if she had symptoms for which “an ordinarily prudent person” would have consulted a health care provider in this time frame, then she would be excluded from receiving LTD benefits under the Prudential Plan due to the pre-existing condition exclusion.

In its June 2016 denial of Plaintiff’s LTD benefits claim, Unum determined that her MS was a “pre-existing condition” under both the Unum Long-term Policy and the Prudential Plan. Unum concluded that because Plaintiff had been treated for “neurological symptoms including unsteady gait and numbness on the right side” on January 21, 2015 and January 26, 2015, and she had been “referred to [Neurologist] for ‘possible MS’” on February 20, 2015, she had a pre-existing condition that precluded her from coverage under the Long-term Policy. Moreover, Unum determined that because Plaintiff had been treated for an eye condition called Pars Planitis on November 20, 2014 – which Unum contended was “directly related” to Plaintiff’s MS – Plaintiff’s condition of MS was pre-existing and therefore excluded from coverage.

Unum’s conclusion was based on a medical records review performed by its clinical consultant, who was a Registered Nurse rather than a medical doctor with an appropriate specialty. Unum also contended that its conclusion regarding the connection between Plaintiff’s Pars Planitis treatment and her subsequent MS diagnosis was allegedly supported by her Neurologist.

Bayer’s Appeal

Plaintiff appealed Unum’s denial of her LTD benefits claim in November 2016, and submitted an Affidavit from her Neurologist and MS expert which confirmed, in relevant part, as follows:

4.   That Pars Planitis is one symptom of possible MS;

5.   That not all patients who have Pars Planitis have MS;

6.   That not all MS patients have Pars Planitis; 

7.  After reviewing the MRI of October 5, 2012, after the time Kim Bayer was diagnosed with Pars Planitis, it is my opinion she did not have MS at that time; . . .

10. That Kim Bayer’s onset date for MS is January 26, 2015 and her treatment for MS began after January 26, 2015.

Nevertheless, in January 2017 Unum denied Plaintiff’s appeal. In denying Plaintiff’s appeal, Unum again relied on Plaintiff’s treatment for Pars Planitis, but Unum also claimed – for the first time – that Plaintiff’s October 2014 visit to a doctor’s office for “peripheral neuropathy” also supported a denial of Plaintiff’s claim. In its letter, Unum claimed that its “medical staff confirmed peripheral neuropathy is a symptom associated with Ms. Bayer’s ultimate diagnosis of multiple sclerosis.” The medical staff to whom Unum refers is another nurse clinical consultant who reviewed Plaintiff’s medical records but also did not conduct an examination of Plaintiff herself. Plaintiff notes that her visit to Dr. Le was due to tingling and numbness associated with a foot rash she had, and that she had this rash since at least 2005, long before her MS diagnosis.

The District Court Decision

Following Unum’s denial of Plaintiff’s LTD benefit claims, as well as her appeal of her claim denials, Plaintiff filed suit in US District Court pursuant to ERISA. After reviewing the administrative record, the Court found that the evidence did not support the conclusion that Plaintiff’s MS was a “pre-existing condition” under the Prudential Plan – for which Unum was subject to a “continuing coverage” clause – such that it warranted a denial of her LTD benefits claim. Plaintiff’s MS would be considered a “pre-existing condition” under Unum’s Long-term Policy because Plaintiff had been treated for “neurological symptoms including unsteady gait and numbness on the right side” on January 21, 2015 and January 26, 2015, and she had been “referred to a Neurologist for ‘possible MS’” in February 2015, which is within the relevant look-back period for the Unum Long-term Policy.

However, the Court concluded that there is no evidence to show that Plaintiff’s MS was a pre-existing condition under the relevant look-back period for the Prudential Plan. Although Unum tried to claim that Plaintiff’s treatment for Pars Planitis in November 2014 was “directly related” to her MS, her Neurologist clarified that although Pars Planitis is a symptom of possible MS, not all patients who have Pars Planitis have MS and vice versa and Plaintiff’s onset date for MS was January 26, 2015.

Moreover, the court also noted that no Unum physicians ever examined Plaintiff in person; indeed, no Unum physicians ever even spoke to a single one of Plaintiff’s treating physicians. The Court noted that although “courts have no warrant to require administrators automatically to accord special weight to the opinions of a claimant’s physician,” a plan administrator “may not arbitrarily refuse to credit a claimant’s reliable evidence, including the opinions of treating physicians.” Here, the Court noted, Unum relied on the conclusions of its “clinical consultants” – who were not medical doctors or MS specialists – and disregarded the opinions of Plaintiff’s treating physicians. More specifically, the Court found troubling the fact that the Unum employee who concluded that Plaintiff’s “treatment for Pars Planitis was directly related to [Plaintiff’s] condition of [MS], and the treatment occurred during the 3 months prior to the effective date of coverage under the prior carrier’s policy,” was a “Disability Benefits Specialist” who did not have any medical degree.

Further, although Unum asserted that it reached its conclusion based on a review by Unum’s clinical consultant, it was clear that this consultant too was not a medical doctor, let alone an MS specialist. Similarly, when Plaintiff appealed Unum’s denial of her LTD benefits claim, Unum’s Lead Appeals Specialist again relied on Plaintiff’s treatment for Pars Planitis to uphold the denial, but also concluded that Plaintiff’s October 24, 2014 visit to a doctor’s office for “peripheral neuropathy” supported a denial of Plaintiff’s claim. This conclusion was based in part on another clinical consultant who did not have any medical degree and who did not conduct an examination of Plaintiff herself.

Conversely, Plaintiff’s treating Neurologist had 16 years’ experience as a physician specializing in the diagnosis and treatment of MS and moreover, she has been the Program Director of a nationally recognized Multiple Sclerosis Center since 2010. Despite her significant experience as a physician and MS specialist, Unum arbitrarily disregarded her opinions in favor of clinical consultants who are not medical doctors, let alone MS specialists. 

In conclusion, the Court found that the record was replete with medical evidence supporting Plaintiff’s argument that her MS was not a pre-existing condition under the Prudential Plan and Unum failed to have a medical doctor or MS specialist examine Plaintiff – or even review her medical records – before reaching the incorrect conclusion that her treatment for Pars Planitis and doctor’s visit for peripheral neuropathy were directly related to her MS. Accordingly, the Court held that the claimant had met her burden of showing that she was disabled within the meaning of the policy and was not subject to the pre-existing condition exceptions. As a result, the Court reversed Unum’s decision and reinstated Plaintiff’s LTD benefits.

This case was not handled by our office, but it may provide claimants guidance in their pursuit of compensation of disability insurance benefits.  Please feel free to contact our office and to speak with one of our disability attorneys for a review of your disability insurance policy and to discuss how we may be able to assist you in securing benefits.

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