District Court Overturns Unum’s Termination of Disability and Life Waiver of Premium Claims; Remands Claims to Unum to Decide Entitlement To “Any Occupation” Benefits

In Radmilovich v. Unum Life Ins. Co. of Am., __F.Supp.3d__, 2023 WL 7457118 (C.D. Cal. Nov. 7, 2023), California Central District Judge David O. Carter granted judgment to Plaintiff David Radmilovich under a de novo standard of review, finding that there was sufficient evidence to establish by a preponderance of the evidence that Plaintiff continued to be disabled from his own occupation and entitled to further long-term disability (“LTD”) and life waiver of premium (“LWOP”) benefits under the policy.

Plaintiff was an industrial engineer employed as Senior Director of Production at Prudential Overall Supply, when on August 28, 2016, he suffered a cardiac arrest resulting in permanent, life-altering changes including unpredictable chest pain episodes, nausea and fatigue, and cognitive loss. After initially granting Plaintiff’s claim for LTD and LWOP benefits, effective September 25, 2018, Unum terminated these benefits in February 2020.

Plaintiff contended that Unum’s termination of benefits, which it upheld on appeal, was improper because he suffered from multiple cardiovascular medical conditions that made workplace stress likely to expose him to further cardiac events, as well as cognitive deficits resulting from oxygen deprivation that made it impossible for him to perform the material duties of his job. Unum argued that Plaintiff’s medical records since his cardiac arrest in August 2016 demonstrated that he was without functional impairment from either a cardiac or cognitive perspective and that he was therefore neither totally disabled under the terms of the plan nor entitled to LTD benefits.

Finding, under a de novo review, that Plaintiff had demonstrated entitlement to further benefits, the Court reached the following principle conclusions of law:

• Unum’s physicians relied on a generic list of occupational activities that they regularly apply to people in professions differing from Plaintiff, rather than the specific requirements of Plaintiff’s job. By assessing Plaintiff’s capacity to perform generic occupational demands rather than the specific duties of his job, Unum’s doctors failed to fully apply the standard of disability articulated in the policy, which requires consideration of whether Plaintiff was unable to perform “with reasonable continuity the substantial and material acts necessary to pursue [his] usual occupation in the usual and customary way.” The Court stated: “It is well-established that insurers must consider the insured’s actual job activities.”
• With regard to evidence acquired after Unum terminated benefits, the Court stated, “medical evaluations made after the expiration of a claimant’s insured status are relevant to an evaluation of the pre-expiration condition.” The Court also noted that a medical diagnosis is often imprecise, so the fact that a doctor’s opinion may change over time does not alone render it incredible. In the case of Plaintiff’s alleged disability due to his cardiac condition, the Court found no reason to question his treating provider’s ultimate diagnosis of ischemia simply because the diagnosis changed over time after additional testing and diagnostic inquiries and became conclusive after Plaintiff had applied for LTD benefits when his symptoms worsened further. It also found that the diagnosis was further bolstered and supported by the conclusions of another of Plaintiff’s treating providers, and both physicians concluded that Plaintiff should not be working in a stressful job.
• The Court rejected Unum’s argument that Plaintiff’s performance on treadmill stress tests proved he could tolerate the stress of his occupation, noting that treadmill stress tests alone cannot measure a claimant’s ability to perform an occupation.
• The Court further found that in rejecting Plaintiff’s reports of chest pain, dizziness, nausea, and cognitive impairment, Unum relied solely on the reports of reviewing physicians, who did not examine or speak with Plaintiff. The Court reiterated that while paper reviews are acceptable under ERISA, their use to discount a patient’s report of their own symptoms is questionable. Moreover, the reports of Plaintiff’s treating physicians confirm his symptoms and provide a physical etiology explaining that they stem from his cardiac arrest in 2016.
• As for Plaintiff’s cognitive impairment, the Court noted the fact that these deficits alone may render Plaintiff disabled from his own occupation, and are corroborated by Unum’s own hired expert, who agreed with the treating physician that Plaintiff suffered from Mild Neurocognitive Disorder. Furthermore, the Court found compelling the explanation of another of Plaintiff’s treating physicians as to why a diagnosis of “mild neurocognitive disorder” does not mean that the impact on Plaintiff was “mild,” but would in fact substantially impede his ability to perform the specific duties of his occupation. And, considering that it was statistically extremely unlikely that Plaintiff would survive his cardiac arrest, and accompanying deprivation of oxygen for 5-20 minutes, without cognitive deficits, the Court found his complaints of his cognitive problems were entitled to greater weight.

Based on the totality of the evidence, the Court concluded that the record established by a preponderance of the evidence that Plaintiff was totally disabled from his own occupation and remanded the matter back to Unum to determine if Plaintiff was entitled to benefits under the any occupation standards of both the LTD and LWOP policies.

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