Carianne Deroo (“Deroo”) worked as an employee for Beaumont Hospital as a Clinical Nurse II. This role involved full-time work as a registered nurse which required patient care. Through her employment with Beaumont Hospital, Deroo was covered by a long-term disability benefits policy which was administered by Unum Life Insurance Company of America (“Unum”). The policy language provides that a claimant is allowed to receive benefits if, as a result of an injury or sickness, she is being regularly treated by a physician and she is “unable to perform the duties of any gainful occupation for which [she is] reasonably fitted by education, training or experience.” A gainful occupation is further defined as “an occupation that is or can be expected to provide you with an income within 12 months of your return to work, that exceeds . . . 60% of your indexed monthly earnings, if you are not working.”
In April of 2012, Deroo applied for long term disability benefits as a result of “left lower extremity lymphedema.” Deroo had ceased working in October 2011 because she had pain and swelling in her left leg which had “progressively gotten worse in [the] past year.” Deroo explained that she was unable to work because she “was unable to stand/sit for prolonged periods of time; increase in pain/swelling with activity.” By June 2012, Unum granted her claim, citing the onset of her disability as of October 2011 and that Deroo was “unable to perform the material and substantial duties of your occupation due to the symptoms related to your medical condition of Lymphedema of the left leg.”
Deroo’s treating physician, Dr. Justin Riutta, M.D., stated that in April of 2012, Deroo’s condition caused “significant restrictions with standing and walking which preclude her from a return to work” and that “[s]he will be off work for the next three months.” Another treating physician, Dr. Cordell Yoder, M.D., cited in June of 2012 that Deroo “is unable to stand or keep the leg in a dependent [sic] [for more than] three minutes.” Because of these opinions, Unum agreed that Deroo was “precluded from performing the material and substantial duties of her occupation” but intended to contact her “in approx 2 months to monitor her response to treatment as the prognosis is unclear at this time.”
By August of 2012, Deroo had applied for Social Security disability benefits and was granted the same with an onset date of January 25, 2012. In August of 2014, Unum chose to terminate Deroo’s long term disability benefits because “you are able to perform the duties of other gainful occupations.” Particularly, Unum believed that Deroo could work full-time as a Nurse Triage or in a Nurse Consulting position. Deroo challenged this decision and in February 2015, Unum reversed its decision based on Drs. Riutta and Yoder’s “opinions of your client’s functional capacity.” In October 2016, Unum again decided that Deroo was not disabled. Deroo appealed and Unum denied the same in July 2017.
The court then reviewed the entirety of the record before making its decision on this matter. It first reviewed Deroo’s own statements regarding her abilities. In particular, it focused on her statement that she needs to “elevate my left leg throughout the day, a pillow under it at night, the swelling is terrible, the range of motion is terrible.” In concert with these statements, an Administrative Law Judge had also reviewed Deroo’s file for her Social Security disability determination. He found that she was disabled because “there are no jobs in the national economy that the individual could perform.”
The court then examined Deroo’s own treating physicians’ documentation. Dr. Riutta explained that Deroo may have been able to perform sedentary work which “would allow for positional changes and elevating the leg at waist level intermittently during breaks.” Dr. Yoder, however, indicated that Deroo was unable to perform sedentary work that “allow[s] for positional changes and elevating the leg at waist level intermittently during breaks” because “[p]atient with severe lymphedema & chronic pain creating/causing an inability to work effectively.”
Next, the court reviewed other consulting physicians’ opinions. Dr. Moises Alviar, M.D., examined Deroo at the behest of the Social Security Administration. He concluded that Deroo would be able to sit for two hours, stand for one hour, and walk for two hours during an eight-hour workday. A consultant named Deborah Ainscough, R.N. reviewed Deroo’s file and opined that she “would be able to wear her compression garments daily and elevate her LLE at or above waist level intermittently throughout the day during breaks along with positional change as needed.” A Dr. Chris Bartlett, M.D. also reviewed Deroo’s record and concluded that she “may lack predictable and sustained full-time (8-hour) functional capacity for sedentary or light (DOT) activities,” but “from 4/14/14 forward” she may have “capacity for 4 hours per day of sedentary or light (DOT) activities.”
Similarly, Dr. A. Catriona Shepherd M.D. and Dr. Joseph Sentef, M.D. indicated that Deroo might be able to perform sedentary work that “would allow for positional changes and elevating the leg at waist level intermittently during breaks.” Alternatively, Deroo’s rehabilitation counselor, James Fuller, opined that Deroo was “unemployable” because she “could not pass the CPR test, and the taking of narcotic pain medication is clearly a factor to be considered in any patient care type of employee.” In contrast, Unum’s vocational rehabilitation consultant Carrie Gregor stated that Deroo would be able to do the “Alternate occupations of Triage Nurse and Medical Claims Review Nurse.”
Overall, the court ruled that a job does not exist that Deroo is qualified for which allows her to elevate her leg to waist level and higher at will. More particularly, the jobs of Triage Nurse and Medical Claims Review Nurse may allow Deroo to elevate her leg, but at lesser frequencies, than she would need. Therefore, because a job that is suitable for Deroo does not exist, the court ruled in favor of Deroo and against Unum, granting her 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: