District Court Upholds Unum Life’s Termination of ERISA Long Term Disability Benefits After Concluding Claimant Was No Longer Disabled by Physical Conditions

In Elias v. UNUM Life Insurance Company of America, No. 21-CV-1813 (WMW/TNL), 2023 WL 375649 (D. Minn. Jan. 24, 2023), District Judge Wilhelmina M. Wright upheld Unum Life Insurance Company of America’s (“Unum Life”) termination of long-term disability (“LTD”) benefits under the Employee Retirement Income Security Act of 1974 (“ERISA”), finding that Unum Life did not abuse its discretion in concluding that Plaintiff’s physical conditions were no longer disabling and discontinuing benefits after 12 years.

Plaintiff was employed as a field representative for Applera Corporation when he ceased working in June 2008 due to several mental health conditions including anxiety, depression, panic disorder, agoraphobia and post-traumatic stress disorder (“PTSD”).  Unum Life approved LTD benefits based on Plaintiff’s depression and PTSD.  In December 2008, Plaintiff presented for the first time with physical symptoms, including severe lower back pain, degenerative lumbar discs with radiating pain into his limbs, and right shoulder pain.  In August 2010, Unum Life informed Plaintiff that the 24-month limitation on LTD benefits due to mental illness would expire, but that it would continue to review Plaintiff’s eligibility for benefits stemming from “any non-psychological medical conditions.”  Thereafter, Unum Life approved continued LTD benefits but did not specify what medical conditions formed the basis of that decision.

Between 2010 and 2016, Plaintiff continued to experience both mental and physical symptoms and was subsequently diagnosed with fibromyalgia, headaches, sleep apnea, osteoarthritis, and chronic pain. In November 2020, Unum Life asked Plaintiff’s physician to confirm that Plaintiff’s physical conditions precluded him from performing his physical job duties. The physician responded that she had “no opinion” on Plaintiff’s “functional capacity.”  Unum Life’s in-house registered nurse conducted a clinical review and opined that, based on Plaintiff’s recent medical records, particularly his reported 80 percent improvement in pain and normal physical condition in examinations, he could return to work.  Unum Life terminated LTD benefits effective January 6, 2021.

Plaintiff appealed asserting that his pain was so severe that he was seeking permission to end his life through Washington’s Death with Dignity Act, although he did not provide documentation to support this representation. Plaintiff also clarified that the 80 percent reduction in pain discussed in his medical records was limited to his fingers only. Unum Life upheld its decision on appeal after nurse and physician peer reviews each concluded that Plaintiff could return to work, full-time, despite a peer-to-peer call with Plaintiff’s physician who opined that Plaintiff “can rarely exert 10 pounds of force due to fibromyalgia pain and bilateral weakness of arms,” and cannot sit longer than 30 minutes due to back pain and that he has been unable to get his mail at times because the symptoms are so severe. Plaintiff filed suit.

On cross-motions for summary judgment, the Court found that Unum Life “provided a reasonable explanation for its decision, supported by substantial evidence,” noting that the focus under an abuse of discretion standard was whether a “reasonable person could have reached a similar decision … not [whether] a reasonable person would have reached that decision.”  Specifically addressing Plaintiff’s contention that Unum Life incorrectly applied the mental illness limitation after having paid benefits for over ten years, the Court found that (1) consistent with the Plan language, Unum Life expressly informed Plaintiff that the 24-month mental health limitation would be exhausted as of 2010 and that any benefits awarded after 2010 would be based on non-psychological medical conditions; and (2) to the extent Plaintiff contends that the 24-month mental health limitation applies only when the claim is based exclusively on mental health conditions, the plain language of the provision belies this contention. Finally, the Court held that Plaintiff’s arguments with respect to Unum Life’s history of bias in claims administration were insufficient to justify finding Unum Life abused its discretion, as there was no evidence of claims bias presented during the time period of Plaintiff’s claim.

As this case demonstrates, it can be difficult to convince insurers of continued disability even after the insurer has paid over 12 years of LTD benefits and with continued treating physician support. If Unum Life has denied or terminated your disability insurance claim, contact us for assistance.