District Court Grants in Part and Denies in Part Cross-Motions for Judgment in ERISA Long-Term Disability Action

In Haag v. Unum Life Insurance Company of America, No. 22-CV-03130-TSH, 2023 WL 6960369 (N.D. Cal. Oct. 20, 2023), California Northern District Magistrate Judge Thomas S. Hixon granted in part and denied in part both parties’ motions for judgment in this ERISA disability action.

Plaintiff was employed by Huntington Memorial Hospital as a Clinical Lab Scientist (a light-duty occupation), and a participant in Huntington’s employee welfare benefit plan, which included long-term disability coverage insured by Unum. Plaintiff ceased working in August 2019, due to lumbar spondylosis with neural compression, and radiculopathy. After physical therapy, medications and epidural injections, Plaintiff resumed work on modified duty in November 2019, but stopped again in January 2020 and underwent lumbar surgery. Plaintiff’s condition initially improved after the surgery, but then she continued to have pain. According to medical records, Plaintiff’s communications with her heath care providers were varied in their reports of pain, including statements of ongoing pain, improvement in pain, and no increased pain. In July 2020, on referral to a new specialist, Plaintiff was diagnosed with piriformis syndrome and resumed epidural injections with added piriformis injections. Plaintiff also continued physical therapy and was prescribed medication for her prior diagnosis of fibromyalgia. On October 19, 2020, Unum determined that Plaintiff was disabled from August 6, 2019, through April 28, 2020, asserting that Plaintiff’s ongoing complaints, post-surgery, did not appear associated with her lumbar disc bulge or discectomy, and that she would not be precluded from a light duty occupation as of that date.

On appeal, Plaintiff submitted updated physical therapy records and a Functional Capacity Evaluation (“FCE”), documenting restrictions and limitations as follows: sit for 30 minutes continuously for up to 4 hours a day, stand for 15 minutes continuously for up to 1 hour a day, and walk for 10 minutes continuously for up to 1-and-a-half hours a day. Plaintiff also underwent an MRI of her hip, which showed a labral tear. On September 27, 2021, Plaintiff underwent right hip surgery to repair the tear. Unum upheld its decision on appeal after its reviewing physician acknowledged Plaintiff’s reported pain and symptoms but found that limited examination and diagnostic testing/imaging findings did not support the severity of impairment reported. The reviewer concluded that Plaintiff was able to perform light duty activity. The parties agreed that Plaintiff did return to work as a Lab reporting Analyst for Heluna Health in August 2022.

On de novo review, the Court found that Plaintiff met her burden of showing it was more likely than not that she was unable to perform her role with “reasonable continuity” beyond April 27, 2020, when Unum terminated benefits. The Court found that Plaintiff’s ongoing reports of pain and symptoms made it clear that she was still experiencing severe back and leg pain and would not have been able to substantially and materially perform the acts that she had been routinely performing at her position. The Court further noted that Unum appeared to be recharacterizing Plaintiff’s ongoing disability as a recovery from surgery, but its initial approval of the claim belied such characterization. The Court also found Plaintiff’s was credible in describing her pain and symptoms to multiple providers over the relevant time period, stating that none of her treating providers indicated any credibility concerns. Unum speculated that Plaintiff’s motivation for not returning to work was related to her mental health and stress, as opposed to pain from her lumbar condition. However, the Court found no indication in the record that this was the reason Plaintiff stopped working. Finally, while Unum’s reviewing physician concluded that Plaintiff’s level of pain was not supported by the medical evidence, the Court found that Plaintiff’s fibromyalgia diagnosis likely was a contributing factor in her reports of pain and did lend credibility to the symptoms she described. As for the objective evidence, the Court found that even though the FCE was somewhat less relevant based on the lapse in time, it still corroborated Plaintiff’s self-reporting at the time of claim closure. And, Plaintiff’s treating providers also recorded objective assessments of Plaintiff’s symptoms and limitations, including a 2021 hip MRI showing a labral tear, and diagnosis of piriformis syndrome.

However, based on Plaintiff’s own characterization of the evidence, the Court found no indication that Plaintiff was disabled after December 7, 2021, two and a half months after surgical repair of the labral tear to her hip. Her surgeon reported she was doing well with only mild pain. Plaintiff herself did not report any pain as of her declaration dated February 11, 2022, and she returned to work in another occupation in August 2022. Accordingly, the Court found that the administrative record showed that Plaintiff was disabled for the period of April 27, 2020, through December 7, 2021, but not thereafter.

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