Court Finds Unum’s Use of Nurse Review to Deny Long Term Disability Claim and Appeal Did Not Comport with ERISA Regulations

In Black v. Unum Life Ins. Co. of Am., No. 3:22-CV-2116-X, __F.Supp.3d__, 2024 WL 873536 (N.D. Tex. Feb. 29, 2024), Texas Northern District Judge granted partial summary judgment to Plaintiff, finding that Unum did not follow ERISA’s procedural requirements, and remanded the claim for a full and fair review.

For many years, Plaintiff received monthly long-term disability benefits through her employer under a plan administered and insured by Unum. In September 2021, Unum terminated Plaintiff’s disability claim because it determined she was no longer disabled. Unum’s decision was upheld on appeal after Unum’ reviewing nurse concluded there was no medical disagreement among Plaintiff’s physicians regarding her functionality.

By the instant motion, Plaintiff sought summary judgment of her ERISA action asserting that she was denied a full and fair review of her claim because: (1) Unum terminated her benefits based on a “medical judgment”; and (2) it failed to consult with a qualified health professional on appeal. Applicable ERISA regulations dictate that a full and fair review is not met unless several procedural requirements are met, in particular that (1) when an “adverse benefit determination … is based in whole or in part on a medical judgment,” the appeal must include consultation “with a health care professional who has appropriate training and experience in the field of medicine involved in the medical judgment,” and (2) the healthcare professional consulted in an appeal may not be the same individual who has consulted in connection with the original determination.

The Court found that Unum violated both of these regulations. First, the Court found that Unum’s initial denial of Plaintiff’s claim was based on a medical judgment, noting that when an insurer relies on consultations with doctors and medical records to deny a claim under its policy, that denial is based on a medical judgment. Second, because the adverse benefit determination was based on a medical judgment, Unum was required to consult with a health care professional who had appropriate training and experience in the field of medicine involved in the medical judgment when deciding the administrative appeal. Unum did not. On appeal, Unum’s nurse reviewer summarized the medical opinions of Plaintiff’s treating physicians and found no indication that Plaintiff could not perform sedentary work within those opinions. The Court noted that this process was problematic because Unum relied on the same physician opinions to initially deny Plaintiff’s claim and to deny her appeal. The Court found Unum’s contention that its nurse reviewer need only be able to summarize the opinions of Plaintiff’s treating physicians was inaccurate. It stated that while ERISA does not require the reviewing physician to have the exact same specialty as the claimant’s treating physician, Unum’s reviewer was not a physician, and Unum did not even contend that she had the appropriate training and experience.

Accordingly, the Court granted Plaintiff’s motion for partial summary judgment on this threshold issue and remanded the matter back to Unum to conduct a full and fair review of Plaintiff’s claim consistent with ERISA’s procedural requirements.

If Unum or your insurer has denied your disability insurance claim, contact us for assistance.