Court Finds Plaintiff Failed to Meet His Burden of Proof for Long-Term Disability

On April 7, 2023, the United States District Court for the District of Massachusetts decided an ERISA long-term disability insurance case against the Unum Insurance Company of America. The Court ruled in favor of Unum.

The claimant 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. The claimant 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

The claimant appealed the termination of benefits. During the administrative appeal period, the claimant submitted additional information, including a Physical Residual Functional Capacity Assessment (“FCE”).

Under the subject long-term disability insurance policy, if a mental illness and physical disability causes the disability, Unum’s Benefits Center Claims Manual (“the Claims Manual”) states that an individual may apply a physical limitation concurrently. Notably, the 24-month mental illness limitation does not apply when there is a concurrent physical impairment.

While the claimant was receiving benefits for anxiety and depression, one of his treatment providers notified Unum that he had chronic pain, a potential physical disability.

The claimant 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. The claimant also submitted medical records supporting his claim.

Unum reviewed the appeal and hired 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 the claimant lacks functional capacity because of any physical conditions to complete job functions. Another medical professional, Dr. Haller, came to a similar conclusion. Unum also hired Dr. Bright to perform a consultation. Dr. Bright agreed with Dr. Jha and Dr. Haller.

The claimant had a Functional Capacity Examination (FCE) during the appeal period. The FCE noted that he “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, Dr. Bress, conduct a medical review. As for the FCE, Dr. Bress pointed out that the FCE stated the claimant’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, 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 [the claimant], and the diagnostic evaluations did not support the presence of autoimmune/connective tissue disease or inflammatory arthritis.”

Legal Arguments

The claimant asserted that Unum’s doctors did not fairly review his claim and that the Court should, therefore, overturn its decision to deny LTD. He also contended that the reviewing physicians did not have the proper credentials to review his claim.

Unum argued that the claimant 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 because of physical disability.

The Court Rules Against The Claimant

The Court found, “The claimant 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, the claimant is not only required to provide objective medical evidence of the existence of his chronic pain. The claimant 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, “The claimant’s treating physicians did not provide sufficient explanations to prove that he 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 the claimant is unable to perform the demands of a sedentary occupation.”

It was a tough decision against the claimant and in favor of Unum.