Harmon v. Unum – LTD Claim For Facilities Technician With A Back Injury Terminated

A facilities technician who received long-term disability (LTD) benefits from Unum for several years following back surgery lost his case after the insurer terminated his claim and the court found the decision was reasonable and supported by substantial evidence. The court rejected his arguments challenging Unum’s medical reviewers, vocational analysis, and alleged conflict of interest.

Joey Harmon filed suit against Unum Life Insurance Company of America after it terminated his long-term disability benefits, which he had been receiving for several years following a back injury and surgery. Harmon had been employed as a facilities technician for 24 Hour Fitness, and his benefits were provided under a Unum policy.

Unum’s termination decision rested on several layers of review: a clinical analysis by a consultant nurse, a vocational assessment, a review of Harmon’s self-reported daily activities, and an Administrative Law Judge’s denial of his Social Security disability claim. Taken together, Unum concluded he could perform the duties of other gainful occupations and was no longer disabled under the policy’s terms.

Mr. Harmon appealed Unum’s denial. The internal appeal process involved a comprehensive review of Mr. Harmon’s medical records, additional assessments by healthcare professionals, and a vocational analysis to determine whether the initial denial aligned with the policy terms and the available evidence.

Unum ordered an additional clinical analysis conducted by a physician board-certified in internal medicine, who concluded that “based on the weight of the medical evidence submitted, there is no physiologic evidence to support ongoing impairment which would support inability to perform” the functional requirements of “occasional lifting up to 20 pounds, frequently up to 10 pounds; frequent sitting with occasional standing, walking with ability to make positional changes.”

Unum upheld its decision to terminate Mr. Harmon’s claim, citing the opinions of the reviewing physicians, the SSA ALJ’s decision that Plaintiff did not qualify as “disabled” under Social Security’s rules, and a substantial gap in the claimant’s treatment.

The claimant thereafter filed a lawsuit against Unum.

The plaintiff presented various reasons to argue that Unum’s denial of benefits was “arbitrary and capricious.” These arguments can be grouped into three main categories:

• First, the plaintiff questioned the validity of Unum’s medical assessment during the appeal process. He argued that Unum based its decision on the opinions of internal staff, who were not specialized in orthopedics, while disregarding the input of the plaintiff’s doctors.
• Second, the plaintiff contested Unum’s assessment of his ability to work, highlighting inconsistencies in Unum’s vocational analysis and a mismatch between the job offered and the policy requirements.
• Lastly, the plaintiff claimed a conflict of interest regarding the defendant that the Plaintiff argued influenced the unjust termination of his benefits, supported by extensive documentation dating back to 2004.

The Court then specifically addressed each category:

• As for the first argument, the Court ruled that Unum’s evaluation of the medical evidence was reasonable, stating, “Unum’s reliance on its medical professionals’ evaluations does not weigh in favor of finding that Unum’s decision to terminate Plaintiff’s claims was arbitrary and capricious.”
• Second, the Court found that Unum’s vocational analysis was not flawed. Although there were errors, the court concluded that Unum’s evaluation and determination did not amount to being arbitrary and capricious.
• Finally, the Court ruled that Defendant’s conflict of interest does not weigh in favor of a conclusion that the decision to terminate the claim was arbitrary and capricious. Plaintiff failed to provide “significant evidence that the use of in-house medical professional reviewers affected Unum’s decision to terminate Plaintiff’s benefits.”

The court ultimately found that none of the arguments, whether considered individually or together, proved that Unum’s decision to deny benefits was arbitrary and capricious. Despite Mr. Harmon’s statements regarding his disability and inability to work, the court upheld the insurer’s decision to terminate LTD benefits because it resulted from “a deliberate, principled reasoning process” and was “supported by substantial evidence.”