Legal Summary: Mitchell v. Unum Life Insurance Company of America
Mitchell v. Unum Life Insurance Company of America
Not Reported in Fed. Supp. (2023)
Our client initially received short-term disability (“STD”) benefits due to multiple medical conditions, including orthopedic conditions, cardiac conditions, and other chronic health conditions, including conditions verified by MRI.
Under Unum’s plan, “you” (how the insured person is referred to in the policy) are considered disabled when Unum determines that you are limited from performing the material and substantial duties of your own occupation due to your sickness or injury; and you have a 20% or more loss in your indexed monthly earnings due to the same sickness or injury. You must be under the care of a doctor to be considered disabled.
To be eligible to receive long-term disability benefits, you must be continuously disabled for 180 days.
Unum approved our client’s short-term benefits, but then denied the STD benefits 12 days before the end of the STD period. Unum refused to reconsider their denial of STD benefits after our client appealed, claiming that it had not received any treatment records in two months, and that those records failed to support a finding that our client could not sit more than 20 minutes at a time. However, her employer, who was responsible for paying the STD benefits, later agreed to pay the other 12 days of benefits.
Our client, through her attorney, applied for the long term disability (“LTD”) benefits that should have begun after she was disabled for 180 days. Unum denied the long term disability benefits, claiming there was a lack of support in the record, and our client asked for a reconsideration of the denial.
Our client’s cardiologist opined that our client was totally incapacitated and could walk only 200 feet due to her shortness of breath and chest pain. He determined that she could not perform her job as a “property manager” as it required her to walk from building to building. Our client’s pain-management specialist wrote that our client would be unable to work as a legal secretary because she could not sit for more than 20 minutes at a time because of severe pain due to cervical and lumbar degeneration disc disease.
In support of her appeal we provided medical records from her rheumatologist, three different internal medicine physicians, her cardiologist, a pain management specialist, a family medicine physician and an ear, nose, and throat physician.
Our client’s most recent physician wrote that, based on our client’s reported symptoms, she was unable to perform sedentary work even with positional changes. Unum’s onsite physician, Dr. Sabrina Hammond, concluded that an internal review of our client’s medical file was sufficient to determine her functional capacity and, as such, an independent examination was unnecessary.
Unum denied the claim, but we appealed. We provided newly obtained MRI evidence which was not available to Unum during the initial review of the claim. Unum upheld its decision to deny additional disability benefits.
We then sued Unum in federal court under the Employee Retirement Income Security Act of 1974 (‘ERISA”) again, asserting Unum should have to pay our client’s LTD benefits.
As part of the lawsuit, we filed a Motion to Determine Deference, asking the Court to determine that Unum’s decision-making process in this case was so tainted by its own financial interests (thus creating a conflict of interest) that the deference afforded Unum in reviewing its decision should be far less than it otherwise would.
The Court used the “arbitrary and capricious” standard of review because Unum’s policy grants it discretion in deciding on our client’s claim. Sandeen, 2022 WL 966848, at *1. Under this standard, the Court must consider any conflict of interest created when a plan administrator decides benefits eligibility and pays the benefit. Metro. Life Ins. Co. v. Glenn, 554 U.S. 105, 115 (2008).
The Court also maintains that an administrator’s decision to deny benefits under an employee welfare benefit plan may be 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. Shaw v. AT & T Ben. Plan No. 1, 795 F.3d 538, 547 (6th Cir. 2015); see also Card v. Principal Life Ins. Co., 17 F.4th 620, 624 (6th Cir. 2021.)
Holding an administrator’s decision is arbitrary and capricious if it fails to consider all the evidence in the administrative record. The Court must review the “quantity and quality of the evidence in the record.” Gilchrest v. Unum Life Ins. Co. of Am., 255 F. App’x 38, 42 (6th Cir. 2007).
Two of our client’s treating doctors opined that our client was totally disabled, but Unum rejected their opinions because it concluded, both at the initial claims and appeals level, that there was a lack of objective medical evidence to support those opinions. Unum further argues, citing Gilrane v. Unum Life Ins. Co. of Am., No. 1:16-CV-403-TRM, 2017 WL 4018853 (E.D. Tenn. Sept. 12, 2017), that because of the lack of objective medical evidence, Unum was not required to conduct an IME of Plaintiff before denying her claim. See Gilrane, 2017 WL 4018853, at *8
The Court determined that the MRI we provided, which was taken three days after our client’s alleged onset of disability, alters its analysis. Unum failed to properly consider the objective findings in the MRI, potential confirming a severe condition.
Unum’s onsite physician, who reviewed our client’s file, ignored the newly received information in the MRI Report and failed to address what effect it may have had on her functional capacity and reported pain levels.
The Court determined that Unum should have provided an independent medical examination before reaching a decision on our client’s claim. This omission of the MRI evidence is important as Unum argued that an IME of our client was not necessary since there was no objective medical evidence which could support our client’s treating physician’s opinion or her reports of pain.
Because of these errors by Unum, the court determined that Unum acted arbitrarily and capriciously in denying benefits. Because the court determined Unum acted arbitrarily and capriciously considering its decision making process alone, the court said that it did not need to rule on our motion to determine the extent of deference to determine whether Unum’s bias and conflict of interest had influenced its decision making.
The court then decided the remedy, whether to award benefits, or remand to Unum to require Unum to properly consider all the evidence. The court explained that remand was appropriate, “where doubt does exist, reversal and remand is … appropriate for a procedural reason such as failure to consider all the evidence or applying the wrong standard.” Card, 17 F. 4th at 624-25 (citing Elliott, 473 F.3d at 618-21; Killian, 152 F.3d at 521-22).
The Court determined that the case should be remanded to Unum for explicit consideration by a physician—preferably one with some specialty in diseases of the spine—as well as an Independent Medical Examination to determine whether there is an HNP pressing on the spinal cord at C5-6, and to assess Plaintiff’s functional vocational capacity considering that finding.
