Drew A. Carson (“Carson”) was an attorney employed by Miller Goler Faeges LLP. Through his employment, he was covered by a long term disability benefits plan which was administered by Unum Life Insurance Company of America (“Unum”). The plan explained that:
“‘Disability’ and ‘disabled’ mean that because of injury or sickness:
- The insured cannot perform each of the material duties of his regular occupation; or
- . . . [W]hile unable to perform all of the material duties of his regular occupation on a full-time basis is: performing at least one of the material duties of his regular occupation or another occupation on a part-time or full-time basis; and earning currently at least 20% less per month than his indexed pre-disability earnings due to that same injury or sickness.”
Further, proof of continuous disability and regular visits by a doctor must be provided, while a 180 day elimination period from the date of the injury to the date of receipt of benefits must be met. After that elimination period, proof of the claim must be made within thirty days. If a legal action is not brought within three years after the proof of claim is required, the claim will be barred.
Carson had been experiencing health issues since 2003, including sleep apnea and insomnia. By July 2011, Carson’s billable time began to decrease, even though his pay had not reflected the same. However, by November, he was completely unable to work and ceased working at the law firm. Soon thereafter, Carson filed a disability claim with Unum explaining he was unable to perform his job duties as a litigator, such as “appearing in court, researching, drafting, [and] communicating with clients.”
Prior to the claim, in 2010, Carson had a “debilitating physical injury” which caused “bilateral chronic groin pain.” He then saw five different doctors to assist in determining what the origin of his pain was and what might resolve it. Carson then had multiple MRIs performed, as well as a consultation with two more doctors. Dr. David Grischkan opined that there was an athletic pubalgia. As a result, Carson participated in exploratory surgery on September 8, 2011. Dr. Grischkan noted a thickened band next to the conjoined tendon, and he put in Gore-Tex mesh for reconstruction.
By March of 2012, Carson was experiencing “crippling complications” which caused him to have a second surgery to remove the Gore-Tex mesh. This was done by Dr. Diya Alaedeen. After the second surgery, Carson’s medical records ceased. Carson, however, did provide medical records from other treating doctors, a psychiatrist, and a psychologist. His psychologist, Dr. David Pincus, stated that Carson was “partially disabled throughout 2011, significantly so by July 2011, and fully by November 2011.” Carson’s psychiatrist, Dr. Omar Elhaj, opined that he had major depressive disorder, panic disorder, generalized anxiety disorder, and sedative and hypnotic abuse. Dr. Kevin Trangle also said that Carson had been “disabled and unable to work in his full capacity since February 2011 and unable to work at all since July 2011.”
When Carson filed his claim on December 8, 2011, Unum had one of its psychiatrists review his file. Dr. Nicholas Kletti opined that the evidence did not show “psychiatric restrictions and limitations” or “any impairment.” He also asked Dr. Pincus for additional records but did not find any other restrictions, referring the case to Dr. Stuart Shipko. Dr. Shipko also found that there were no disabling restrictions. Unum then had Dr. Elhaj and a Dr. Mansoor Ahmed to explain Carson’s limitations, but neither of them provided restrictions from work or any other limitations. As a result, Unum denied Carson’s claim because it appeared that he was able to perform his job duties.
Carson appealed, but Unum never received any additional documents. Dr. Peter Brown then reviewed Carson’s file but did not find evidence of a disability. Therefore, on December 11, 2012, Unum affirmed its denial of Carson’s appeal. On January 22, 2013, Carson again appealed and submitted two additional documents. One document was a November 30, 2012, supplemental report from Dr. Elhaj, and the other was a December 31, 2012 report by Dr. Tragle. Based on these reports, Unum requested additional information from Dr. Tragle.
The new information was reviewed by Dr. Brown, Richard Cole, R.N., and Dr. Laina Rodela. From their review, Unum was able to determine that Carson had limitations from September 8 to October 5, 2011, and from March 10 to July 18, 2012. However, there was no evidence to indicate that there was a continuous physical disability during the 180 day elimination period. Dr. Brown then suggested that the claim be denied, which Unum chose to do on September 3, 2013. Carson then filed the instant suit.
Carson’s main argument is that Unum was arbitrary and capricious in denying his benefits because Unum conducted file-only reviews of his medical records. Carson alleges that file-only reviews are not favorable when relating to mental illness or chronic pain. However, “opinions of treating physicians should not necessarily be accepted over those of reviewing experts simply because the treating physician physically examined the claimant.” The court indicated that the Sixth Circuit previously ruled that there is nothing wrong with a file-only review if it is conducted by a qualified physician in relation to a benefits determination. Because of this, the court believed that Unum did not act in an arbitrary and capricious manner.
The court also felt that the doctors who did review the files came to their own conclusions in a reasonable manner. Unum particularly had three different reviews done by four different medical professionals. Again, the court did not find that Unum had acted arbitrarily and capricious because of this.
Lastly, Carson was in disagreement regarding Unum’s decision that he was not disabled for the entire elimination period. However, Carson’s medical records indicated that there was a gap in treatment from September 8, 2011, to March 30, 2012. Therefore, the court held that Unum reached a valid conclusion regarding the same. Overall, the court ruled in favor of Unum and against Carson, upholding Unum’s administrative decision.
Disclaimer: This was not a case handled by disability attorney Nick A. Ortiz. The court case is summarized here to give readers a better understanding of how Federal Courts decide long term disability ERISA claims.
Here is a PDF copy of the decision: