District Court Finds Plaintiff-Physician Was Disabled Due to Underlying Medical Conditions and Risk of Exposure to COVID-19

In Downs v. Unum Life Insurance Company of America, No. 23-CV-01643-RS, 2024 WL 3908106 (N.D. Cal. Aug. 19, 2024), on cross-motions for judgment pursuant to FRCP Rule 52, California Northern District Judge Richard Seeborg granted judgment in favor of Plaintiff and against Unum finding that Plaintiff was disabled due to her underlying medical conditions and high risk of COVID-19 exposure in her occupation.

Plaintiff was a 69-year-old pediatric physician who stopped working on February 27, 2020, to undergo surgery for uterovaginal prolapse and a hysterectomy. Shortly after Plaintiff’s surgery, the COVID-19 pandemic surged. The rapidly evolving health landscape had serious repercussions for Plaintiff’s wellbeing. In addition to the risks of COVID-19 posed by her vocation, Plaintiff suffered multiple medical issues placing her at heightened risk of a severe COVID-19 infection including diabetes, hypertension, asthma, obstructive sleep apnea, as well as her history of heart attack, breast cancer, and fatty liver disease. On May 22, 2020, Plaintiff submitted a claim for long-term disability benefits to Unum, enclosing an attending physician statement from her PCP highlighting Plaintiff’s heightened COVID-19 risks and complications as well as her depression as the basis for her disability. Thereafter, Plaintiff’s PCP submitted a second form outlining that due to Plaintiff’s chronic medical conditions, her age, and her work as a pediatrician she is at high risk for COVID-19 complication and that Plaintiff was accordingly advised to limit her patient exposure until the pandemic situation improved.

Unum denied the claim opining based on the file reviews of two “on-site” physicians, internist Dr. Robert Nosaka and physiatrist Dr. Jamie Lewis, that Plaintiff would not be restricted from working as a physician since Plaintiff had the ability to reduce the risks associated with COVID-19 exposure with the use of personal protective equipment (“PPE”) and preventative measures as outlined by OSHA. Unum upheld its decision on formal appeal, and the instant lawsuit followed.

From the outset the Court noted that no controlling authority has explicitly decided whether a present condition that puts a beneficiary at high risk of COVID-19 but would not otherwise prevent them from completing their usual occupational responsibilities constitutes a disability. The Court noted that several of Plaintiff’s medical conditions and comorbidities were known and remain COVID-19 risk factors as outlined by the CDC. Plaintiff was also 70 years old when she filed her claim, which placed her at even greater risk of COVID-19 infection. Unum did not contest these facts but rather characterized Plaintiff’s concerns about returning to work as a simple “decision” she undertook due to her “fear of COVID-19,” rather than a prophylactic measure taken to protect herself. The Court disagreed, finding that Plaintiff’s concerns were not so trivial. In March of 2020, the state of COVID-19 was not what it is today. Following a rapid spread of severe illness and death globally, governments imposed stay-at-home orders to protect individuals from infection. While most were able to shift their employment from the workplace to home, many were unable to make this transition. In the pre-vaccine era, the risk of COVID-19 to those individuals loomed large. During this time, Plaintiff’s vocation as a pediatric physician exposed her to “known or suspected COVID-19 patients,” putting her “high exposure risk” for the virus even according to Unum’s physician, Dr. Nosaka.

In reaching its conclusion, the Court analyzed cases supporting the argument that a risk of harm or death from returning to work can indicate a disability. It noted the case of Evans v. UnumProvident Corp., 434 F.3d 866 (6^th Cir. 2006), in which the Sixth Circuit held that a nursing home administrator who suffered from a seizure disorder was disabled within the meaning of her long-term disability policy because her ordinary work was high stress and likely to trigger seizures. Id. at 879. In Evans, the Court held that an existing illness that was likely to manifest into a future injury if the plaintiff returned to work constituted a disability.

The Court acknowledged Unum’s point that the risk-of-relapse theory has often failed, but distinguished cases cited by Unum, including Stanford v. Continental Casualty Company, 514 F.3d 354, 360 (4^th Cir. 2008), where the Fourth Circuit rejected the risk-of-relapse theory and held that a nurse anesthetist living with substance abuse disorder was not disabled within the meaning of her LTD disability policy. The Court reasoned that unlike a doctor with a heart condition who enters a high-stress environment like an operating room “risks relapse” in the sense that the performance of his job duties may cause a heart attack, an anesthetist with a drug addiction who enters an environment where drugs are readily available “risks relapse” only in the sense that the ready availability of drugs increases his temptation to resume his drug use. Whether he succumbs to that temptation remains his choice; the heart-attack prone doctor has no such choice.

The Court found that Plaintiff’s claim aligned with the facts in Lasser v. Reliance Standard Life Insurance Company, 334 F.3d 381, 383 (3d Cir. 2003), where the Third Circuit held that an orthopedic surgeon was disabled within the meaning of his long-term disability policy because the stress of his occupation was likely to exacerbate his condition and cause a heart attack. The surgeon’s present condition was disabling not because it physically prevented him from completing his work, but because a return to work was likely to exacerbate the condition into a serious injury. The district court in that case noted that “[i]t is a basic tenet of insurance law that an insured is disabled when the activity in question would aggravate a serious condition affecting the insured’s health … Where medical prudence requires a cessation of work activity, the insured is disabled.” Lasser v. Reliance Standard Life Ins. Co., 146 F. Supp. 2d 619, 628 (D.N.J. 2001), aff’d, 344 F.3d 381 (3d Cir. 2003).

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