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 (2019)
Our client suffered from coronary artery diseases, insomnia, fibromyalgia, and ongoing chronic back pain, which forced her to stop working as a property manager. At this time, she filed for short term disability benefits from Unum Life Insurance and received benefits for two months. Afterwards, she reapplied
She appealed, but Unum declined to reconsider its denial of short term disability benefits, arguing that our client’s records failed to support her claims and that it had not received further treatment records.
After this denial, she retained our services, and we filed a claim for long term disability benefits. Under Unum’s policy, the insured must be continuously disabled for 180 days to receive long term disability benefits, which it argued our client was not. Unum denied this request, claiming that our client did not have sufficient medical evidence. We filed an appeal, arguing that Unum’s decision was arbitrary and capricious as it had not conducted a proper independent medical examination of our client in order to assess the severity and limitations of her condition.
Unum requested a list of our client’s attending physicians, records and medical opinions concerning our client’s functionality. Together with our client, we gathered medical evidence including physicians’ statements, self-reports, and various records that Unum had not previously reviewed, including an MRI file.
Unum again denied the claim. We sued under ERISA, arguing that Unum failed to properly consider the medical evidence, including the MRI. Unum also wrongly rejected our client’s physicians’ opinions and wrongfully claimed a lack of objective medical evidence. We also argued that Unum failed to conduct an independent medical examination of our client before denying her claim, which Unum should have done under the policy and ERISA’s rules.
The court applied an arbitrary and capricious standard of review, giving the benefit of the doubt to the insurance company. However, the court noted that under this standard of review, a plan is considered arbitrary and capricious if the administrator ignored key pieces of evidence, selectively reviewed the evidence it did consider from the claimant’s treating physicians, or failed to conduct a physical examination while relying heavily on non-treating physicians.
The court found that Unum “incorrectly characterized the impressions” of the MRI results. The court also found that Unum failed to properly consider our client’s herniated nucleus pulposus (herniated disc) pressing on her spinal cord. Citing these failures, the court remanded the case to Unum for further proceedings, including an independent medical examination.
