District Court Denies Summary Judgment and Allows Unum to Submit an Amended Final Determination Letter in ERISA Long-Term Disability Action

In Rogers v. Unum Life Insurance Company of America, et al., No. 22-CV-11399-AK, 2024 WL 1466728 (D. Mass. Mar. 31, 2024), Massachusetts District Judge Angel Kelley denied both Plaintiff and Defendant Unum’s Motions for Summary Judgment, finding that the court required more information to determine whether Unum’s decision to deny Plaintiff’s long-term disability (LTD) claim was arbitrary and capricious, and directing Unum to prepare an amended final determination letter.

Plaintiff first sought and Unum awarded short-term disability (STD) benefits through the 26-week maximum benefit period for disability. Thereafter, Unum denied Plaintiff’s LTD claim, concluding that Plaintiff failed to provide evidence that he was unable to perform the demands of his occupation due to “Mixed Connective Tissue Disease, chronic pain, and Emphysema … difficulty raising [his] left shoulder, confusion, brain fog, severe fatigue, arthritis in [his] left shoulder, left knee, ankle, and hands” along with myositis, skin lesions, cluster headaches, fevers, and difficulty with his hands. Plaintiff appealed. The appeals process included a vocational assessment of Plaintiff’s occupation; new medical reviews conducted by Unum medical consultants and others. Unum affirmed its denial of Plaintiff’s LTD benefits, stating that the appeals medical consultants disagreed with Rogers’ attending physicians. Unum also discussed the IME results indicating that Plaintiff was capable of light work, and that Unum’s policy defined his occupational duties as they are defined nationally, and not what Plaintiff actually did for his employer.

Thereafter, Plaintiff submitted notice of his award of Social Security Disability Insurance (“SSDI”) benefits, and a vocational assessment indicating that his duties required medium work and concluding Plaintiff had been “unable to perform the material duties” of this occupation throughout the relevant time period. Unum conducted another vocational review and again concluded that Plaintiff’s scientist position required “light capacity” in terms of work demands, confirming its prior conclusion. The instant lawsuit followed.

On cross-motions for summary judgment, Unum argued that its decision was “reasoned and supported by substantial evidence”, while Plaintiff argued that Unum abused its discretion by denying his LTD claim notwithstanding: (1) remaining impaired after receiving STD benefits; (2) the opinions of his treating physicians; (3) determining Plaintiff required indefinite FMLA leave during the same timeframe; (4) the award of SSDI; and (5) the vocational assessment that Unum’s occupational classification was incorrect.

The Court reviewed the matter under the arbitrary and capricious standard of review, and in light of Unum’s 2005 Regulatory Settlement Agreement (“RSA”) in which Unum agreed that significant weight is to be given to attending physician opinions. And, for Unum to reject the attending physician’s opinion, “the claim file must include specific reasons why the opinion is not well supported by medically acceptable clinical or diagnostic standards and is inconsistent with other substantial evidence in the record.”

The Court found that while Unum’s medical consultants did explain their conclusions in general, their failure to explain why the attending physicians’ conclusions did not meet the standard nor identify inconsistencies, created a dispute of fact as to whether it followed its own Policy by attributing the proper weight to the attending physician opinions. It noted first that Unum did not challenge the credentials of Plaintiff’s attending physicians, but rather their conclusions as to Plaintiff’s functional capacity. The Court criticized the adequacy of the reviews conducted by Unum’s employed medical consultants. It found that medical consultant, Dr. Scott Norris (Occupational Medicine), provided little to no explanation as to why the specific attending physicians’ opinions were not well supported by medically acceptable clinical or diagnostic standards, as required by Unum’s Policy. The IME physician, Dr. Ronald Rapoport (Rheumatology), did not address any of the attending physicians’ conclusions. And, while Dr. Rapoport concluded that Plaintiff had the capacity to “perform full-time, light work activity if his fatigue did not intervene excessively,” he also emphasized that Plaintiff’s description of his work duties appeared to exceed the designated description of “light work.” The court further found that while Unum physician, Dr. Peter Brown (Psychiatry) properly addressed why he disregarded the opinion of one of Plaintiff’s treating physicians (Dr. Tufo), he failed to address any of the other treating physician opinions. Similarly, the Court found that each of the reviews by Unum physicians, Dr. Donna Kim (Family Medicine), Dr. Arlen Green (PM&R) and Dr. Stephen Kirsch (Family Medicine) all failed to address why they believed the opinions of Plaintiff’s treating physicians were not “well supported” as required by RSA.

Finally, the Court noted that while Unum’s medical consultants did address and distinguish Plaintiff’s award of SSDI, it found that Unum did not offer any explanation for the inconsistency of Unum’s award of FMLA leave during the same time frame as the LTD decision, which suggested that Unum’s decision was arbitrary. The Court denied the parties motions for summary judgment and directed Unum to produce an amended final determination letter to include specific reasons why each attending physician’s opinion is not well supported by medically acceptable clinical or diagnostic standards or is inconsistent with other substantial evidence in the record, and to address the FMLA finding.

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