Client v. Unum Life Insurance Company of America

The court ordered Unum to pay our client benefits because contrary to Unum’s denial decision, our client adequately demonstrated that she was disabled from fibromyalgia and that it prevented her from working.

Our client served her employer as the director of operations, a top executive position, before she had to stop working because of severe joint and muscle pain. Her pain appeared to be mostly attributable to fibromyalgia and seronegative rheumatoid arthritis. Because of her conditions, our client received short term disability benefits through her employer.

Later, our client applied for long-term disability (LTD) benefits, but Unum denied her request, asserting that there was not enough evidence to corroborate her disability. Unum’s reviewing physician talked to our client’s treating physician who explained why she thought our client’s medical conditions rendered her unable to work. Nevertheless, Unum’s physician still doubted our client’s disability and ordered an independent medical examination (IME).

The doctor who conducted the IME concluded that our client could still work, despite evidence to the contrary. For example, the doctor concluded that our client “experienced tenderness in eight out of eighteen joints,” needed “good support system[s] at home and work” due to her fibromyalgia, and required “frequent breaks with stretching exercises [and] relaxation techniques to carry out her day at work and home.” To make matters worse, the doctor only physically touched our client’s hands during the examination, even though she made conclusions about our client’s pain in other joints. Based on the report on this IME, Unum’s vocational rehabilitation specialist concluded that our client could continue her job. So, Unum denied our client’s claim for LTD benefits and leave without pay.

We helped our client appeal, providing more information supporting her disability. Notably, her appeal included a functional capacity examination, in which the evaluator concluded that our client would be unable to work for at least 30% of an eight-hour work day. In addition, the appeal contained statements from multiple treating doctors supporting our client’s claim as well as sworn declarations from our client’s husband, mother-in-law, and former supervisor stating that our client was a dedicated employee before she began experiencing extreme symptoms from her disability.

Unum responded to our client’s appeal with another denial letter, confirming its position that our client was not disabled and could continue to work. The denial was based upon Unum’s reviewing doctor’s opinion that our client’s “claim of disability was not supported,” but rather, the “lack of observable physical symptoms and [our client’s] failure to respond to therapies” was consistent with a non-disabling case of fibromyalgia. We sued challenging Unum’s denial. 

First, the court noted that our client’s record discussed two potentially-disabling conditions (fibromyalgia and seronegative rheumatoid arthritis), and with respect to at least fibromyalgia, every physician who reviewed our client’s case concluded that the symptoms she experienced “were consistent with a diagnosis of fibromyalgia.” 

Further, fibromyalgia is difficult to physically diagnose; it requires individuals to self-report symptoms from which physicians can conclude that the condition exists. Despite this, Unum tried to argue that relying on our client’s description of her symptoms was not a valid foundation for concluding that she suffered from fibromyalgia. The court rejected that argument, because as noted, the nature of fibromyalgia requires self-reporting and Unum had “not presented any evidence that would suggest that any other source of diagnostic information…is so comprehensive and reliable as to render self-reporting of symptoms to be beside the point.”

In addition, the court emphasized the fact that our client didn’t rely exclusively on self-reported evidence; she also offered corroborating evidence of her medical condition in the forms of medical records, treating physician opinions, and statements from family members. Our client additionally submitted a functional capacity evaluation that supported her disability, which was important according to the court, because the Sixth Circuit has held that such evaluations are valuable objective evidence of fibromyalgia. On top of that, one physician who claimed to be skeptical of our client’s disability acknowledged physical evidence of multiple symptoms that were consistent with fibromyalgia.

Given the solid evidence of fibromyalgia, the court addressed whether or not the condition rendered our client unable to perform her job. Our client’s evidence, according to the court, confirmed that our client’s symptoms made “it effectively impossible for her to reliably work complete days, even in a sedentary position.” Unum’s evidence, on the other hand, was “mostly unpersuasive and based on the unsupported and conclusory” legal contention that our client could not be disabled given the lack of physical markers.

Notably, the court also highlighted that our client’s “history of professional success and dedication to her career tends to weigh against any inference that she would falsify or exaggerate her symptoms to avoid her career responsibilities.”

Lastly, Unum tried to convince the court not to give too much weight to our client’s treating physicians. While it is true that “the opinion of a treating physician ‘does not have to be afforded special deference,’” the court explained that there are also cases, such as our client’s, where “a treating physician’s greater experience with a plaintiff may…provide that physician with a superior basis for making certain determinations.” Indeed, fibromyalgia requires relying upon self-reported symptoms to diagnose, so opinions from treating physicians are particularly valuable.

Overall, the court concluded that based on the administrative record, our client had “carried her burden of establishing her disability,” and Unum’s arguments were “simply insufficient to rebut [our client’s] case…” On that basis, the court reversed Unum’s denial and awarded our client benefits.