Case Name: Mary Allen v. Unum Life Insurance Company of America
Court: U.S. District Court for the Eastern District of Virginia
Date of Decision: September 1, 2016
Type of Claim: Long Term Disability
Insurance Company: Unum Life Insurance Company of America (“Unum”)
Claimant’s Employer: CVS Pharmacy
Claimant’s Occupation / Job Position: A pharmacy technician. Her job includes assisting pharmacy customers, processing prescriptions, performing register transactions, communicating with healthcare providers, inputting data into the computer, and managing inventory. The physical activities required include “repetitive wrist-twisting motions of opening and closing prescription and stock bottles, typing, typing while talking on the phone (cradling the phone between the shoulder and neck), reaching above the head to remove bottles from shelves, and standing for extended periods of time without sitting.” Unum classified this occupation as requiring a light level of physical exertion.
Disabilities: In March 2010, Allen suffered multiple injuries in a car accident, including neck, back, arm, and leg injuries, primarily on the left side of her body. After the accident, Unum paid Allen short-term disability benefits through August 2010. During this time, Allen visited several doctors and tried various avenues for pain management, including physical therapy and chiropractic care. In July 2010, she returned to working half shifts for ten to fifteen hours per week, with a limitation from performing “anything in [her] job description that could exacerbate or potentially reinjure [her].” In September 2010, Allen returned to work full-time with the same limitation against doing anything that could exacerbate her injuries.
While working full-time, Allen continued visiting various doctors and showed some improvement, but her pain persisted. In February 2012, Allen underwent spinal surgery, which fused two vertebrae in her neck. After the surgery, Unum paid short-term disability benefits through July 2012. While the surgery seemed to improve the pain in Allen’s neck and arm, the pain in Allen’s back and leg persisted. Allen and her physicians continued exploring techniques to manage the pain, including epidural injections and aquatic therapy, in addition to chiropractic care.
In June 2012, Allen returned to work part-time with the following physical restrictions and limitations: no lifting of 10 lbs. above the waist; no cradling phone; no twisting or bending; no staying in one position for greater than one hour; and no work greater than four hours, three times per week.
Definition of Disability in the Plan/Policy: The Plan contains two different definitions of long-term disability. For the first twenty-four months, an employee qualifies as disabled if “[she is] limited from performing the material and substantial duties of [her] regular occupation due to [her] sickness or injury.” In contrast, after twenty-four months, the employee is disabled if she is “unable to perform the duties of any gainful occupation for which [she is] reasonably fitted by education, training or experience.” In other words, for the first two years of benefits, an employee is “disabled” if she cannot perform her regular job. After two years, an employee is disabled only if she cannot perform any occupation.
Other Key Definitions in the Plan/Policy: Unum has “sole discretionary authority to construe the terms of the Plan and all facts surrounding claims” and to make benefits determinations.
Benefits Paid? Yes. After using up her short-term benefits, Allen applied for long-term disability benefits. Unum approved these benefits under the “regular occupation” standard, beginning July 2012. Allen continued to work part-time, but still experienced pain and, at some point, began having headaches. Allen reported to her physician that the headaches occur “after 1-2 hours of walking on concrete in the pharmacy. They will also occur if she is at work and has to sit for 1 1 /2 hours consecutively. She has observed that while sitting, if she can change position every 30-45 minutes she can prevent the headaches.” While working part-time, Allen continued to see various doctors, and Unum intermittently evaluated her claim for benefits.
Basis For Denial / Termination of Benefits: In August 2014, Unum discontinued Allen’s benefits. To justify its decision, Unum cited Allen’s improvements with headache patterns, Unum’s physicians’ reviews of Allen’s medical records, and Allen’s ability to work part-time at CVS.
Procedural history: Allen filed an appeal of the termination of benefits. On December 11, 2014, Unum denied Allen’s appeal. The denial letter recounted the initial decision, as well as the review by and conclusion of its neurosurgeon during the appeal. The letter also listed information “inconsistent with the severe symptoms and the degree of physical difficulties and/or limitations that [Allen] describes.”
Key Physician Opinions: In March 2014, Unum notified Allen that it would evaluate her claim for continuing long-term disability benefits under the “any gainful occupation” standard beginning July 2014. As part of its review, Unum contacted Allen’s physicians for their opinions on Allen’s capacity to work full-time in a sedentary occupation. Allen’s primary care physician, her chiropractor, and her neurologist all agreed that Allen could not work full-time in a sedentary occupation. Unum retained an internist and a neurologist to review Allen’s medical records and other documents in the claim file. Both agreed that Allen could perform a mostly sedentary occupation on a full-time basis.
Issues: Allen makes three main arguments: (1) Unum had a conflict of interest that tainted the decision; (2) Unum wrongly relied on its consulting physicians over Allen’s treating physicians; and (3) Unum wrongly relied on the idea that the ability to work part-time at a light level of exertion suggested the ability to work full-time in a sedentary capacity.
Holdings: (1) Nothing in the record suggests inherent bias based on Unum’s conflict of interest; after all, Unum paid Allen the maximum amount of short-term disability and paid long-term disability benefits for two years. (2) Neither the Plan nor ERISA prohibits plan administrators from seeking medical opinions from consulting physicians based on a review of the claimant’s medical file. See, e.g., Spry v. Eaton Corp. Long Term Disability Plan, 326 F. App’x 674, 679 (4th Cir. 2009). … Accordingly, Unum did not abuse its discretion in relying on the opinion of its consulting physicians over Allen’s treating physicians. (3) While the Court agrees with Allen to the extent that sedentary work does not necessarily beget more sedentary work, light-level-exertion work and sedentary work differ. While CVS did accommodate Allen to an extent, the record reflects that she did more than sedentary work during her shifts. In fact, Allen reported that CVS would not provide a rubber mat to alleviate the pain associated with standing on a concrete floor. Thus, Unum did not abuse its discretion in translating Allen’s ability to work part-time in her position at CVS into evidence of an ability to work full-time in a sedentary occupation as a factor in its decision to deny Allen benefits.
Summary: Unum came to a reasonable decision after a principled decision-making process. Unum received the opinions of Allen’s treating physicians, had two physicians render opinions after reviewing Allen’s full medical records, and evaluated other information gleaned from its interactions with Allen. Based on this information, Unum denied Allen benefits because it found that she could perform a full-time sedentary occupation. Unum then denied both of Allen’s appeals after reviewing the new evidence submitted and after two more consulting physicians agreed that Allen could perform a full-time sedentary occupation. While Unum made some mistakes with its denial of Allen’s second appeal-namely, the Facebook profile mix-up-these mistakes do not negate the full and fair review Allen received before the second appeal, see infra Part III.B, and, in any event, are harmless. Accordingly, although the Court may have reached a contrary conclusion independently, Unum did not abuse its discretion in denying Allen’s claim for long-term disability benefits.[Note: this claim was not handled by the Ortiz Law Firm. It is merely summarized here for a better understanding of how Federal Courts are handling long term disability insurance claims.]
Here is a copy of the decision in PDF: Allen v. Unum