In Harmon v. Unum Life Insurance Company of America, et al., No. 1:20-CV-318-KAC-CHS, 2023 WL 4166085 (E.D. Tenn. June 23, 2023), Tennessee Eastern District Judge Katherine A. Crytzer granted judgment to Unum Life finding that its termination of Plaintiff’s ERISA-governed long-term disability (“LTD”) claim was not arbitrary and capricious.
Plaintiff was a Facilities Technician at 24-Hour Fitness, responsible for repairing and maintaining all the buildings and equipment in the facility. In 2012, Plaintiff injured his back while at work and underwent back surgery. He filed claims for LTD and life waiver of premium (“LWOP”) benefits with Unum Life. After review of Plaintiff’s medical and workers’ compensation records, Unum Life approved both LTD and LWOP benefits and continued to pay benefits for several years. By 2017, Plaintiff reported that he had moved to Florida, was no longer engaged in physical therapy, and was doing his “own exercises”, but still could not work due to pain and the need to rest and “respect” his injury. Additionally, an Administrative Law Judge upheld the denial of Plaintiff’s claim for Social Security disability benefits. With this new information Unum Life reached out to Plaintiff’s only remaining treating provider for his opinion. The physician confirmed that Plaintiff had last been seen in September 2017 and did not have a follow up appointment scheduled. The physician also provided a release to functional capacity, but with significant restrictions and limitations.
Unum Life had Plaintiff’s file reviewed by a nurse consultant who concluded that there was no current medical documentation to support Plaintiff being precluded from occasional lifting up to 20 pounds, frequently up to 10 pounds; frequent sitting with occasional standing, walking with ability to make positional changes. A subsequent vocational review identified three gainful occupations, Inspector Component Parts, Final Inspector, and Security Guard, which exceeded 60% of his pre-disability earnings and could be performed within Plaintiff’s education, training, and experience. Unum Life terminated both LTD and LWOP benefits effective November 2017. Plaintiff appealed, both criticizing Unum Life’s evaluation and submitting updated records from his current physician and another with whom he renewed treatment.
Unum Life upheld its decision on appeal after a further medical review concluded that the restrictions and limitation imposed by Plaintiff’s treating providers were inconsistent with his level of personal activity, including working out for 30-45 minutes per day, lifting ten to fifteen pounds, and the underlying organic pathology on prior MRI studies. Plaintiff’s medical records reflected very limited mention of chronic pain issues, no additional pain medication, limited musculoskeletal exams, and unremarkable X-rays. Unum also noted that the medical records did not reflect that Plaintiff was in active treatment when it discontinued benefits, with a gap in treatment from December 2015 to April 2018. The subsequent litigation ensued.
On cross-motions for judgment, Plaintiff (1) argued that Unum’s decision rested on the opinion of one in house, non-examining, file reviewing nurse, and one non-examining file-reviewing internal medicine doctor who is not a specialist in orthopedics; (2) challenged Unum Life’s “vocational analysis claiming that it used the wrong residence location, contradicted itself by determining that Plaintiff did have transferrable skills after previously concluding he did not, and provided an occupation that did not meet the gainful occupation requirement; and (3) alleged that Unum Life’s conflict of interest led to the inappropriate decision to terminate his claims.
Finding in favor of Unum Life, the Court determined that neither policy entitled Plaintiff to review by a physician with a specific specialty. While the policies provided that Unum Life will consult with a health professional with appropriate training and experience, Plaintiff did not offer any evidence that the review physician lacks such appropriate training and/or experience.
Next, the Court found that Unum Life had a reasoned explanation to reject the opinions of Plaintiff’s treating providers. It determined that both the reviewing nurse consultant and physician engaged in a thorough review of the record, noting an overall lack of recent clinical examination or medication for any lower back impairment. And, Plaintiff’s own reports of exercising by lifting weights exceeding the weight restrictions outlined by his doctors further diminished the relevance of the treating provider opinions. The Court further noted that Unum Life’s decision to forego an Independent Medical Examination was permissible, particularly because the file review did not involve a credibility determination.
The Court also determined that Unum Life’s vocational analyses were not flawed. The analyses used Plaintiff’s self-reported location – Miami, Florida – as the relevant job market. Unum Life’s assessments were not contradictory as each of them analyzed differing levels of work capacity (sedentary as opposed to light), and the identification of one alternate occupation that did not meet the gainful wage requirement, when two other occupations were identified, did not render the entire analysis faulty.
Finally, the Court held that Plaintiff did not present concrete evidence suggesting that Unum Life’s conflict of interest affected its decision. There was no indication that any of the claims and appeals personnel involved in Plaintiff’s claim had access to corporate “financial weekly tracking reports” or “closure data” that may have influenced their decision.
The Court concluded that Unum Life’s decision to deny Plaintiff’s claims for LTD and LWOP benefits resulted from “a deliberate, principled reasoning process” and was “supported by substantial evidence.” If Unum Life has denied or terminated your disability insurance claim, contact us for assistance.
*Please note that this blog is a summary of a reported legal decision and does not constitute legal advice. This blog has not been updated to note any subsequent change in status, including whether a decision is reconsidered or vacated. The case above was handled by other law firms, but if you have questions about how the developing law impacts your ERISA benefit claim, the attorneys at Roberts Disability Law, P.C. may be able to advise you so please contact us.
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