District Court’s Decision Affirming Unum’s Termination of Disability Benefits After 10 Years of Payment Highlights the Difficulties for Claimants under the Arbitrary and Capricious Standard of Review

In Eggleston v. Unum Life Insurance Company of America, No. 1:22-CV-23393, 2024 WL 4533607 (S.D. Fla. Oct. 21, 2024), on Cross-Motions pursuant to FRCP Rule 52, Florida Southern District Judge Darrin P. Gayles granted judgment in favor of Unum Life Insurance Company of America and against Plaintiff finding that Unum did not abuse its discretion in terminating long-term disability (“LTD”) benefits after 10 years based on three physician records reviews, and contrary to the results of a Functional Capacity Evaluation (“FCE”) and the opinions of seven treating providers.

Plaintiff was employed as a research nurse at John Hopkins Bayview Medical Center when she stopped working on February 21, 2011, due to multiple chronic pain conditions, including lower back pain, fibromyalgia, sciatica, undifferentiated connective tissue disorder (“UCTD”), bilateral hip pain, greater trochanteric bursitis, and inflammatory arthritis. Unum approved Plaintiff’s LTD claim and paid benefits for 10 years. In September 2021, Unum initiated a social media investigation and found that Plaintiff had multiple posts promoting a “soul food kitchen” with advertised menus and contact information. Social media posts also revealed Plaintiff traveled to Saint Thomas Virgin Islands and Houston, Texas, and attended a three-hour performance in Baltimore. Unum arranged for three medical consultant reviews. Christina Young, R.N., found that although Plaintiff and her physicians continued to assert inability to return to work due to flares of chronic pain and fatigue, the updated medical records documented that her condition was generally stable and controlled with flares described as mild to moderate. Dr. Todd Lyon concluded that while Plaintiff should avoid strenuous activity and heavy lifting, her ongoing work restrictions and limitations were no longer supported, and she could perform full-time sedentary work. Dr. Zachary Gross agreed, stating there were no specific physical findings in the medical records to support that the claimant would be unable to perform occupational demands as outlined. After a transferable skills evaluation identified several occupations within the restrictions and limitations, including triage nurse, utilization review coordinator, and medical claims review nurse, Unum terminated benefits.

On appeal, Plaintiff submitted an FCE report, pain and capacity questionnaires from her treating providers, medical records, and letters from her providers supporting ongoing disability. Her doctors reported that (1) Plaintiff’s pain was severe or moderately severe; (2) she could not sit for more than two hours per day; (3) she could rarely carry more than ten pounds; (4) her pain would be severe enough to interfere with concentration and attention disrupting at least 25% or more of the workday; (5) she would be expected to miss work more than four days a month due to symptoms or treatment; and (6) she could not return to work. Unum upheld the termination on appeal after its reviewers, Jacqueline Ballback, R.N., and Dr. Arlen Green both found that clinical findings did not rise to the level of functional impairment, and Plaintiff’s findings were mainly of self-report. The instant action ensued.

Applying an abuse of discretion standard of review, the Court noted that there were competing opinions as to whether Plaintiff remained disabled, including the opinions of seven treating providers and an independent FCE on the one hand, and the medical record reviews and opinions of three physicians and two nurses on the other. The Court concluded that the findings of Unum’s reviewing physicians, while different from what Plaintiff’s providers or even the Court might opine, were not unreasonable and were supported by evidence in the record. And Unum was not obliged to accord any special deference to treating provider opinions. The Court also noted that Dr. Green found that the FCE failed to show elevation in heart rate during testing, suggestive of invalid results. Even with the existence of Unum’s structural conflict of interest, the Court concluded that Plaintiff failed to demonstrate that Unum’s decision was arbitrary and capricious.

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