Key Physician Opinions: On June 20, 2002, one of the Plaintiff’s treating physicians completed Unum’s Attending Physician Statement. Due to Plaintiff’s symptoms of dizziness, pain, and fatigue, the treating physician opined that Plaintiff was totally disabled. The diagnosis confirmed Plaintiff’s vertigo, otitis media (ear infection), and fatigue symptoms.
Definition of Disability: To prove disability under the subject LTD policy, the claimant must prove:[Y]ou are limited from performing the material and substantial duties of your regular occupation due to your sickness or injury; and[Y]ou have a 20% or more loss in your indexed monthly earnings due to the same sickness or injury.The LTD Policy continues to note that:
after twenty-four (24) months of payments, you are disabled when Unum determines that due to the same sickness or injury, you are unable to perform the duties of any gainful occupation for which you are reasonably fitted by education, training or experience.
“Gainful Occupation is one that within 12 months of your return to work is or can be expected to provide you with an income that is at least equal to 60% of your annual earnings in effect just before your date of disability began.”
Benefits Paid? Unum paid long-term disability benefits for approximately 10 years and then terminated the LTD benefits.
Procedural history: The Plaintiff appealed the termination of benefits. After consideration of the administrative record and the examinations of several physicians, Unum upheld its termination decision under the LTD Policy. “Unum explained that Plaintiff’s conditions, collectively and individually, did not indicate he was precluded from engaging with reasonable continuity in the alternative gainful occupations previously identified by Unum’s vocational staff.”
After exhausting his administrative remedies, the Plaintiff filed a lawsuit.
Plaintiff’s Position: According to Plaintiff, Unum cannot point to significant medical evidence that suggests Plaintiff’s condition has improved warranting Unum to terminate his benefits. Plaintiff challenges Unum’s termination of his benefits because when Unum received Plaintiff’s updated medical records, Unum decided to continue Plaintiff’s benefits. The updated medical records included Dr. Porter’s July 2008, 2009, and 2011 APS reports where he informed Unum that Plaintiff was able to frequently sit, occasionally stand, walk and lift/carry up to 20lbs. Plaintiff claims that these CFS symptoms did not change from July 2008 to August 2011 which means Unum must have relied on evidence that demonstrates a significant improvement in Plaintiff’s condition in order to terminate his benefits. But Plaintiff contends that the significant improvement is absent here. Plaintiff points the Court to Dr. Porter’s medical evaluations and the CPET test which is the test Plaintiff believes is the most important piece of evidence in evaluating Plaintiff’s condition. According to Plaintiff, Unum ignored the CPET test and did not seriously consider its findings before terminating Plaintiff’s LTD benefits.
According to Unum, it relied on a significant improvement in Plaintiff’s condition justifying termination of the Policy. Unum contends that its doctors reviewed Plaintiff’s claims and concluded that the medical record did not support Plaintiff’s CFS diagnosis. Particularly, Unum focuses on Dr. Gannon who examined Plaintiff in-person and confirmed that Plaintiff had no neurological condition or restrictions and limitations. Moreover, Unum’s vocational analysis concludes that Plaintiff could work in “other gainful occupations including computer sales, IT auditor and systems analyst.” Lastly, Unum points out that the CPET is very inconsistent with the administrative record and should not be relied upon as objective evidence.
Issues: Whether Unum’s denial of the Plaintiff’s LTD claim was reasonable.
Holdings: ”Viewing the record through the lens of de novo review, the Court finds that Plaintiff has significantly improved compared to when he was first diagnosed with CFS. … The Administrative Record is clear that Unum’s primary reason for terminating Plaintiff’s benefits is because Unum disputes the impact CFS has on Plaintiff’s ability to perform sedentary work. The Court finds that the medical file supports Plaintiff’s ability to perform sedentary or light work.”
Summary: ”The record, the policy, and the Parties’ arguments do not support the assertion that Plaintiff was disabled as of July 2012 (termination of LTD benefits) and August 2012 (termination of LWOP benefits). The Court therefore has no alternative other than to affirm Unum’s decision to deny Plaintiff’s benefits.”