Tenth Circuit: Unum’s Termination of Long-Term Disability Benefits Was Not An Abuse of Discretion

In an unpublished decision, Isbell v. Unum Life Insurance Company of America, No. 23-1351, 2025 WL 40379 (10th Cir. Jan. 7, 2025), the Tenth Circuit Court of Appeals upheld Unum Life Insurance Company of America’s decision to terminate ERISA-governed long-term disability (LTD) benefits for Plaintiff-Appellant Isbell, a former store manager for Yankee Candle. Unum initially approved payment of benefits when Isbell stopped working due to severe pelvic floor pain and other related conditions. When the definition of disability in the Unum policy transitioned from an inability to perform her regular occupation to an inability to engage in any gainful occupation for which she was reasonably qualified, Unum determined that Plaintiff’s medical evidence did not substantiate an ongoing inability to perform sedentary work. The district court upheld Unum’s determination, which Plaintiff appealed.

The Tenth Circuit applied an abuse of discretion standard and examined whether Unum’s decision was “arbitrary and capricious.” The court considered Unum’s conflict of interest based on its dual role as both the evaluator and payer of benefits but gave the conflict little weight in light of Unum’s efforts to mitigate bias by engaging independent medical reviewers and thoroughly considering Plaintiff’s post-denial medical evidence.

Plaintiff argued that new diagnostic findings, including MRIs revealing conditions like hip dysplasia and torn labrums, provided a basis for her continued disability. However, the court noted that Unum’s decision did not rest solely on the presence of these conditions but rather on whether these conditions precluded her from performing sedentary work. Unum obtained opinions from independent medical experts, including Dr. Winkel, who concluded that Plaintiff’s documented functional capabilities were consistent with the demands of sedentary work. The court agreed that these expert opinions provided a reasonable basis for Unum’s decision.

Plaintiff also argued that her reports of severe pain were not adequately considered by Unum. The court, however, found that Unum reasonably addressed these complaints. Unum’s reliance on evidence of Plaintiff’s daily activities and improvement with treatment, alongside the absence of escalated medical interventions, supported the conclusion that her pain did not preclude sedentary employment. Notably, the court emphasized that while subjective pain is a critical factor, it must be evaluated in conjunction with objective medical findings. Unum’s decision to forego an independent medical examination (IME) did not, in the court’s view, render its decision arbitrary, particularly given the substantial evidence already in the record.

Lastly, the court addressed Plaintiff’s argument that Unum did not fairly consider her Functional Capacity Evaluation (FCE). Unum’s doctor criticized the FCE for documenting Plaintiff’s limp though older physical therapy records did not document a limp. Plaintiff argued that an intervening injection caused the limp, thus, Unum’s doctor’s opinion was unreliable. The court found that Plaintiff misread the physician’s report, which relied on the observations of other providers who saw Plaintiff on multiple occasions. Judgment affirmed.