Our Client v. Unum Life Insurance Company of America
Our client developed severe heart conditions, including ischemic cardiomyopathy, dyspnea and a left bundle branch block, that rendered her unable to continue her work as a grant administrator for a non-profit. She applied for long term disability benefits from Unum Life Insurance, which agreed she was disabled and provided her benefits for two years.
After 24 months of benefits, the definition of Disability in the policy changed to “when Unum determines that due to the same sickness or injury, [someone is] unable to perform the duties of any gainful occupation for which [someone is] reasonably fitted by education, training or experience.” Unum found that our client was not disabled under the any occupation definition of disability in the policy and terminated her benefits. She filed a timely appeal and submitted several opinions from her treating providers outlining restrictions and limitations which prevent her from performing sedentary work. Unum maintained its decision, stating that our client is able to perform sedentary work based on the opinions of its file reviewing physicians. We brought suit on behalf of our client for judicial review of Unum’s decision.
The court reviewed the case under a de novo standard of review, under which the judge draws an independent conclusion based upon materials provided on the record. The court decides the case without deference to the insurance company’s decision.
After a de novo review, the court concluded that our client is unable to perform sedentary work. The court found that the doctors Unum hired to review our client’s claim are less persuasive than the treating provider’s opinions in its evaluation as to whether our client is disabled for several reasons. The court explained that Unum’s file reviewers failed to adequately explain why our client’s medical records indicated she was capable of sedentary work and, instead, simply stated that the restrictions and limitations recommended by our client’s treating providers are not supported by the medical information. One of Unum’s file reviewers noted that our client’s cardiac function had improved, but the court explained that improved cardiac function alone does not mean that our client can perform sedentary work. The court also noted that one of Unum’s file reviewers viewed each of our client’s conditions in isolation without respect to how her cardiomyopathy affects her other health issues. The court noted that such “piecemealed medical opinions” fail to adequately explain why our client is capable of sedentary work
None of Unum’s hired physicians ever performed an examination on our client, rather they chose to rely solely on review files. The court found this problematic because Unum’s file reviewers made credibility determinations and dismissed the opinions of the treating providers without the benefit of an examination that was allowed under the policy.
After examining the medical evidence we presented, the court acknowledged that our client is unable to perform sedentary work and is disabled under the definition of disability in the policy. The court ruled in our favor, determining that Unum wrongly terminated our client’s long-term disability benefits.
