Our Client v. Unum Life Insurance Company of America
Our Client v. Unum Life Insurance Company of America
United States District Court for the Eastern District of Tennessee (2020)
Our client was the CEO of a non-profit before inoperable back conditions, cancer treatments, and labile blood pressure rendered him disabled. These conditions limited his physical mobility and caused him severe pain, and he was unable to continue working. At this time, he filed for long term disability benefits from Unum Life Insurance, and initially received benefits for 24 months.
The claim was approved based on Plaintiff’s osteopenia (a bone condition), but Unum expected our client to get an MRI to track the progress of his osteopenia. However, our client was too sick at the time of the appointment and missed the procedure. A physician later recommended that our client refrain from getting an MRI altogether, saying that he should avoid the radiation due to his having had cancer.
Unum later denied his benefits. Our client requested a reconsideration, but was subsequently denied, with Unum citing its previous recommendation for our client to undergo an MRI. Unum argued that our client’s previous MRI and X-rays supported their decision to deny his benefits, that his functional capacity examination (FCE) was “internally inconsistent,” and that his treating physician’s opinions weren’t supported by medical records. Unum offered the opinions of its own doctors’ and medical reviewers, who argued that our client was not disabled.
After Unum denied his benefits, our client retained our services and we filed an appeal, claiming that we had sufficient medical evidence to show that he qualifies for LTD benefits, and that an additional MRI was not necessary. Evidence included a letter from our client’s physiatrist, a functional capacity examination, a letter from the Social Security Association, and proof of his having received benefits under another disability plan, among other documents.
The court reviewed Unum’s denial under the de novo standard of review because Unum’s policy did not give it the discretionary authority to determine benefit eligibility. Under this standard, the court decides whether the insurance company made the correct decision, and the insured has the burden of proving that they are entitled to benefits.
Unum claimed our client did not provide enough objective evidence to prove that he was disabled, but the court disagreed. The court ruled that our client’s functional capacity evaluation, along with statements and documents provided by his physicians, were sufficient objective evidence for Unum to determine his disability status.
None of Unum’s doctors completed a physical examination of our client, despite having the right to do so. They chose to make decisions based on only his medical review files. However, multiple doctors who did physically examine our client agreed that he could not perform sedentary work.
Based on Sixth Circuit law and the administrative record, the court found the opinions of our client’s doctors, as well as his previous MRIs and X-rays, to be more persuasive than Unum’s conclusions. The court also agreed that a cancer survivor should probably not undergo an MRI, despite Unum’s request, due to radiation exposure.
In response to Unum’s disagreements with our client and his medical professionals’ opinions and evaluations, the court determined that Unum should have examined our client, rather than simply deny his benefits. Taking into consideration our client’s limitations, the court ruled that he cannot perform the tasks of a sedentary occupation, and is, therefore, entitled to disability benefits for 24 months.
Under Unum’s policy, someone receives benefits for 24 months if they are disabled from their regular occupation, not working, and have at least a 20% loss of earnings. However, in order to receive long term benefits after the first 24 months, one must meet a separate definition of disabled. Someone can receive benefits if they are unable to perform the duties of a gainful operation, for which they are “reasonably fitted by education, training, or experience.”
A gainful occupation is an occupation that is expected to provide the insured with an income within a year of returning to work, exceeding either 80% of their indexed monthly earnings (if employed), or 60% of their indexed monthly earnings (if unemployed.)
The court determined that, based on the objective medical evidence, documentation of his inability to work, subjective evidence, and the opinions of physicians, our client proved that he was disabled under the policy. Our client was considered disabled under two of Unum’s definitions, with one pertaining to the first 24 months of a claim and the other pertaining to after those 24 months.
Our client also received benefits from the Social Security Administration. Unum disputed that our client was being overpaid in his benefits because he received money from both Unum and the SSA. Unum sought to recover this cost, but our client had already spent the money provided.
Following the precedent set by the U.S. Supreme Court case Montanile, the court denied Unum’s attempt to recoup these benefits. The court agreed that an insurance company cannot collect overpayment from the insured if that money has already been spent.
After examining our medical and financial evidence, the court determined our client was disabled and remanded the case back to Unum to reevaluate his benefits. The court agreed with us regarding Unum’s attempt to reclaim our client’s prior SSA benefits, ruling that he was not obligated to reimburse anything to Unum.
