In Abi-Aad v. Unum Group, Unum Life Insurance Company of America, No. 21-CV-11862-AK, 2023 WL 2838357 (D. Mass. Apr. 7, 2023), Massachusetts District Judge Angel Kelley granted judgment to Unum finding that Plaintiff did not meet his burden of proving that he remained disabled due to his physical condition after 24 months.
Plaintiff was employed as the Director of Software Quality Assurance at Symbotic, LLC. Plaintiff ceased working in November 2017 due to depression, anxiety and post-traumatic stress disorder and submitted disability claims pursuant to ERISA-governed employee welfare benefit plan insured and administered by Unum. Unum approved and paid maximum benefits on Plaintiff’s claim for Short-Term Disability (“STD”) benefits starting December 7, 2017. Therefore, Unum approved Plaintiff’s Long-Term Disability (“LTD”) claim on the same basis with benefits commencing on March 7, 2018. In May 2019, Unum reminded Plaintiff that his benefits would expire in March 2020 (based on the 24-month mental illness limitation in the Policy).
While Plaintiff was receiving benefits for his mental illness, on February 3, 2020, one of Plaintiff’s treatment providers notified Unum that he had chronic pain, a potential physical disability. Pursuant to the Policy, Unum conducted multiple medical reviews of his condition. After one non-physician reviewer and two reviewing physicians concluded that Plaintiff did not meet the definition of disabled, Unum notified Plaintiff that his benefits reached the maximum benefit period for a mental illness disability and terminated his benefits. On October 16, 2020, Plaintiff appealed Unum’s decision to terminate his LTD benefits and provided additional information, including a Physical Residual Functional Capacity Assessment (“FCE”). Unum submitted the additional materials to two physicians on appeal and upheld its decision to terminate Plaintiff’s claim.
Plaintiff sought judicial review of Unum’s decision to deny LTD benefits asserting that when Unum terminated his disability benefits due to mental illness, he was eligible for continued LTD benefits because he was simultaneously suffering from a physical disability. The Court granted Unum’s summary judgment motion finding that Plaintiff failed to meet his burden to show the Court that there is objective evidence that his chronic pain rendered him unable to perform the duties of a gainful occupation. The Court noted that although it is impermissible to require objective evidence to support claims based on medical conditions that do not lend themselves to objective verification, such as chronic pain, it is permissible to require objective support that a claimant is unable to work as a result of such conditions.
Unum’s medical reviewers found that the treatment records and FCE did not support ongoing disability from a physical condition. Dr. James Haller noted in the FCE that Plaintiff self-limited and some tasks such as the firm grasp and off-of-ground static balance were avoided. Grasping trial reflected variability in results, which is inconsistent with maximum effort. And, Plaintiff’s score on the McGill Pain Questionnaire (44) suggested poor psychodynamics and the potential for unreliable pain reports during functional testing. Dr. Haller concluded that the limiting behaviors on the exam therefore precluded an adequate assessment of capacity and interfered with the ability to draw conclusions regarding Plaintiff’s true physical capacity. Dr. Haller also noted that Plaintiff’s performance during the FCE was inconsistent with the severity of reports and findings in the medical records. Medical reviewer, Dr. Norman Bress also emphasized the potential for unreliable pain reports. Dr. Scott Norris noted that the serial grip and pinch testing showed variation values greater than fifteen percent, which suggested inconsistent effort. Dr. Norris also concluded Plaintiff’s FCE was inconsistent with Plaintiff’s documented minimal examination findings, diagnostic testing, imaging findings, and inconsistency of treatment. The Court found that Unum’s three medical reviewers relied on objective clinical evidence to discredit the FCE’s conclusion that Plaintiff is unable to perform the demands of a sedentary occupation.
The Court further concluded that Plaintiff’s treating physicians did not provide sufficient explanations to prove that Plaintiff is not able to perform a gainful occupation. Although the reports of Dr. Amy Devlin and Dr. Sharon Stotsky supported Plaintiff’s medical condition of chronic pain, they did not support his inability to work.
Finally, the Court rejected Plaintiff’s argument that Unum’s physicians lacked the appropriate licensing and training required to review his claim. It noted that the four reviewing physicians all held licenses to practice medicine in a state in the United States. Three of the reviewing physicians practiced Family Medicine, Dr. Haller, Dr. Bright, and Dr. Norris, which concerns a broad range of experience and training, sufficient to perform a medical review regarding chronic pain. Additionally, Dr. Bress has a board certification in Internal Medicine and Rheumatology, which is the specialization for Plaintiff’s asserted physical disability, chronic pain. As such, the reviewing physicians had the appropriate experience and training to provide a recommendation for Plaintiff’s LTD claim.
As this case demonstrates, it can be difficult to convince insurers of continued disability, particularly in cases of mixed physical and psychological conditions. If Unum 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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