An ERISA long term disability insurance case between Daniel Abi-Aad and Unum was decided on April 7, 2023 by United States District Court for the District of Massachusetts.
The parties filed cross-motions for summary judgment. The Court ruled against the claimant Abi-Aad, and ruled in favor of Unum Insurance Company of America.
Abi-Aad worked with Symbiotic LLC Plan as the Director of Software Quality Assurance. He had worked in the computer software and information technology (“IT”) industry for approximately twenty years.
Abi-Aad received benefits for two years. Unum terminated the claim after two years, under the two year coverage limit for mental health claims. This is a typical termination point for many insurance companies.
Concurrent Mental and Physical Impairments
Abi-Aad appealed the termination of benefits. During the administrative appeal period, Abi-Aad submitted additional information, including a Physical Residual Functional Capacity Assessment (“FCE”).
Under the subject long term disability insurance policy, if the disability is caused by a mental illness and physical disability, Unum’s Benefit Center Claims Manual (“the Claims Manual”) states that an individual may apply a physical limitation concurrently. Importantly here, the mental illness 24-month limitation does not apply when there is a concurrent physical impairment.
Abi-Aad argued that Unum was aware that he had a concurrent physical impairment, and therefore his LTD disability benefits should not have ended after two years.
Abi-Aad submitted medical records in support of his claim.
Unum reviewed the appeal, and hired a Dr. Jha to review the records “to determine whether he had a physical disability that keeps him from performing gainful employment.”
Dr. Jha concluded that the review of the information in the file purportedly does not support that Abi- Aad lacks the functional capacity due to any physical conditions to complete job functions.
A Dr. Haller came to a similar conclusion.
Unum also hired a Dr. Bright to perform a consultation. Dr. Bright agreed with Dr. Jha and Dr. Haller.
During the appeal period, Abi-Aad had a Functional Capacity Examination, or FCE. The FCE noted that Abi-Aad “did not demonstrate the ability to perform within the SEDENTARY Physical Demand Category,” due to “his need to alternate sitting and standing.”
Unum then had a fourth medical reviewer, a Dr. Bress, conduct a medical review. As for the FCE, Dr. Bress pointed out that the FCE stated the Abi-Aad’s performance “would suggest poor psychodynamics and the potential for unreliable pain reports during functional testing,” which would “interfere with the ability to draw conclusions regarding his true physical capacity.”
Unum then had a fifth doctor, Dr. Norris, to perform a final review of the medical evidence. Based on his evaluation of the medical records, Dr. Norris stated that “[t]he limited findings on physical examinations were not [consistent with] the severity of physical symptoms as reported by [Abi-Aad], and the diagnostic evaluations did not support the presence of autoimmune/connective tissue disease or inflammatory arthritis.”
Abi-Aad asserted that Unum’s doctors did not fairly review his claim, and the Court should therefore overturn its decision to deny LTD. Abi-Aad also asserted that the reviewing physicians did not have the proper credentials to review his claim.
Unum argued that Abi-Aad failed to show sufficient evidence that chronic pain renders him unable to perform the duties of any gainful occupation for which he was reasonably fitted by education, training, or experience due to physical disability.
The Court Rules Against Abi-Aad
The Court found, “Abi-Aad fails to meet his burden to show the Court that there is objective evidence that his chronic pain rendered him unable to perform the duties of a gainful occupation.”
The Court stated, “Under the policy, however, Abi-Aad is not only required to provide objective medical evidence of the existence of his chronic pain. Abi-Aad also must show that chronic pain rendered him unable to perform a job for which he was reasonably fitted by education, training, or experience.”
After reviewing the evidence, the Court said, “Abi-Aad’s treating physicians did not provide sufficient explanations to prove that Abi- Aad is not able to perform a gainful occupation.”
The Court sided with Unum’s reviewing physicians: “These three medical reviewers relied on objective clinical evidence to discredit the FCE’s conclusion that Abi-Aad is unable to perform the demands of a sedentary occupation.”
Tough decision against the claimant and in favor of Unum.