From 2002 until 2010, Julia Sun worked as a Registered Nurse caring for quadriplegic patients. Her occupation could not be considered, as far as strength demand was concerned, anything less than a “medium” physical demand level occupation. The substantial and material duties of her occupation included caring, bathing, feeding, dressing and transferring patients. She administered their medications and assessed their condition and illnesses. There was no question that her job was selfless, difficult and required unique skills as well the significant physical ability.
In December 2010, Ms. Sun suffered an injury to her foot. On the advice of her treating physician she took time off of work to focus on recovery and healing. However, her foot never properly healed and she was never able to return to work. Ms. Sun’s treating podiatric physician diagnosed her with plantar fasciitis and possible Peroneal Longus tear. To make matters worse, Ms. Sun did not undergo surgery due to her existing diagnosis of lupus and the medications she was taking to treat her autoimmune disorder.
Approximately 4 months after she stopped working United of Omaha began paying Ms. Sun long-term disability benefits pursuant to her employer sponsored and ERISA governed long-term disability plan.
In February 2012, United requested that Ms. Sun complete an Education, Training and Work Experience Form. Ms. Sun completed and returned the form to United, and indicated that her employment goal was to “[r]eturn to work as an RN in a non-patient care role. Approximately 5 months later United terminated Ms. Sun’s long-term disability claim. Ms. Sun appealed United’s adverse decision submitting additional evidence of disability. Ms. Sun prevailed in her appeal and once again began receiving LTD benefits from United.
United Terminates Sun’s Long-term Disability Claim Following Change In Occupational Definition
After being paid and receiving benefits for 24 months under the Own Occupation definition of the disability and even paying some months beyond that time, United notified Sun that the question of disability was no longer whether she was capable of performing the duties of her own occupation as a registered nurse, but rather that after 24 months the question of disability was now whether Sun was capable of performing all of the material duties of Any Gainful Occupation. United informed Sun that it had determined that she was not disabled from Any Gainful Occupation and that it had decided to terminate her claim for benefits.
As its basis for denial, United stated that it had referred Sun’s case to a medical consultant who reviewed her medical file and determined that although she would continue to have restrictions, those restrictions only included no heavy lifting, pushing, pulling and carrying over 10 pounds, no prolonged standing, walking, climbing, squatting, crawling and kneeling. United also performed a Transferable Skills Analysis (“TSA”) using the information provided regarding Ms. Sun’s education, training and work experience. United concluded that Ms. Sun had the transferable skills necessary to perform a Gainful Occupation of a sedentary strength demand.
Ms. Sun appealed United’s adverse decision within the 180 day timeframe provided for in the denial letter to only have United disregard the additional arguments and medical evidence she submitted and uphold its previous decision.
Ms. Sun filed a lawsuit to recover her long-term disability benefits in the United District Court for the Eastern District of Michigan seeking her unpaid benefits, costs, attorney fees and interest.
US District Court Finds That United Acted Arbitrarily and Capriciously By “Cherry-Picking” The Opinion of Its Medical Consultant
After suit was filed, both Ms. Sun and United submitted motions for summary judgment requesting the court to find in their favor. United also filed a counter-claim requesting that any benefits that Ms. Sun was overpaid on account of her receiving social security disability benefit be paid to United.
After the parties briefed their cases to the judge through motions for summary judgment, the Court found that Ms. Sun was indeed disabled and entitled to benefits and that United had acted arbitrarily and capriciously in denying her claim. The Court found that the “administrative record does not support United’s findings that Sun can perform sedentary work and is not disabled.” Further, the judge specifically identifies that United not only ignored findings by Ms. Sun’s treating physicians that showed Ms. Sun was indeed disabled, but also “cherry-picked” the opinions of its vocational consultant to “find evidence that supports a conclusion in their favor.”
After finding in Ms. Sun’s favor, the Court required United to pay Ms. Sun the benefits that were owed to her, less the amount that Ms. Sun owed United on account of the overpayment of benefits, and directed the parties to attempt to stipulate to a judgment amount for attorney fees, cost and interest.