Legal Summary: Mistick v. Unum Life Insurance of America

No. 19 CV 190, 2020 WL 13442144 (E.D. Tenn. 2020)

We brought suit against Unum Life Insurance Company because our client’s long-term disability benefits were wrongly terminated.

Our client was covered by her employer’s long-term disability plan. Unum paid our client two years of LTD benefits under the “own occupation” definition in the plan, agreeing she was “limited to performing the material and substantial duties of your regular occupation due to your sickness or injury” and had at least a 20% loss of earnings.  However, Unum’s policy included a  change in its definition of “disabled” once two years of benefits were paid to an “any gainful occupation” provision, requiring our client to prove she was “unable to perform the duties of any gainful occupation for which you are reasonably fitted by education, training or experience.” Mistick, 2020 WL 13442144, at 1. 

Unum stopped paying our client benefits after two years, claimed that our client was not disabled.  Despite having paid our client for being unable to do her own occupation for the last two years, when the definition in the policy changed to the “any gainful occupation” definition, Unum found our client was “able to perform the duties of [her] regular occupation on a full-time sustained basis.” Id., at 3. 

We helped our client appeal, gathered more medical evidence, and explained to Unum why they should pay our client her benefits.  Relying largely on the opinion of Dr. Scott Norris, a Unum employee “medical consultant,” Unum found “that ‘examination findings are not consistent with the severe level of impairment [Mistick reports] or with functional limitations to prevent [her] from performing’ sedentary work.” Id., at 4.

We sued Unum on behalf of our client and moved for judgment on the ERISA record, arguing that Unum incorrectly terminated her disability benefits. We argued that she remained disabled per the plan’s definition at the time Unum terminated her benefits as she was unable to perform any gainful occupation. Unum contended that our client was not disabled because her condition did not prevent her from performing sedentary work. 

Courts in ERISA cases review denied claims either under a de novo or a deferential “arbitrary and capricious” or “abuse of discretion” standard of review.  Under a de novo standard of review, the court determines whether the insurance company made a correct decision “apply[ing] general principles of contract law and … read[ing] the plan provisions ‘according to their plain meaning in an ordinary and popular sense.’” Id., at 4.  Under the “arbitrary and capricious” or “abuse of discretion” standard of review courts give the benefit of the doubt to the decision by the insurance company, usually affirming their decision if it is reasonable; however, the deference is more limited when the insurance company is operating under a conflict of interest.

Courts default to the de novo standard unless the beneficiary’s plan “gives the administrator or fiduciary discretionary authority to determine eligibility for benefits or to  construe the terms of the plan,” per Firestone Tire & Rubber Co. v. Bruch, 489 U.S.  101, 115 (1989.) If the plan does contain such language, then the more deferential standard of review applies.

Unum agreed that our client’s plan did not afford Unum the discretionary authority to determine benefit eligibility, so a de novo review was appropriate. Mistick, at 4. The court acknowledged it must rule on whether the insurer properly interpreted the plan and whether the insured is entitled to benefits under said plan. The court also reviews the record without any deference or presumption of correctness to Unum’s decision, following James v. Liberty Life Ins. Co. of Boston, 582 F.  App’x 581, 586 (11th Cir. 2014). 

The court had to decide whether our client’s condition prevented her from performing sedentary work in order to determine if Unum incorrectly terminated her benefits. We had to prove our client’s disability with a preponderance of evidence, per ERISA standards. 

Following the Sixth Circuit decision McClain v. Eaton Corp. Disability Plan, 740 F.3d 1059, 1064 (6th Cir. 2014), under ERISA, a court may consider only the evidence available to the plan administrator at the time the insurer’s decision was made. 

The court acknowledged that the parties presented conflicting medical opinions, with our client treating doctors contending that she could not perform sedentary work.  On the other hand, Unum’s file reviewing doctors claim she could do sedentary work, or at least that the medical file does not support a finding that she cannot do sedentary work. Mistick at 5.

The court first acknowledged that under ERISA law, courts don’t have to “accord special weight to the opinions of a claimant’s physician.” Id. However, insurance companies and other administrators “may not arbitrarily refuse to credit a claimant’s reliable credible evidence, including the opinions of a treating physician.” Id.

The court also explained that when an insurance company relies on a doctor who conducted only a record review and did not examine the claimant, “a claimant’s documented limitations may not simply be dismissed as subjective exaggerations … where … the individuals purporting to make that credibility determination did not meet or examine the claimant.” Id., quoting from Bruton v. Am. United Life Ins. Corp., ––– F. App’x ––––, 2020 WL 398539, at *8 (6th Cir. Jan. 23, 2020).

The court further explained that when it comes to insurance company doctors who only review medical records:

while there is “nothing inherently objectionable about a file review by a qualified physician in the context of a benefits determination,” Calvert v. Firstar Fin., Inc., 409 F.3d 286, 296 (6th Cir. 2005), a physician’s credibility determination is “entitled to little weight” when he conducts a paper review of a claimant’s file, even though the plan gave the administrator the right to have a physical examination conducted, Bruton, 2020 WL 398539, at *9.

Mistick at 5. 

The court found “that the evidence demonstrates [our client]’s cardiomyopathy and related complications prevent her from performing sedentary work.” Id. The court then set out a series of medical findings from her own physicians and the testing they had done. Then the court examined the opinions her treating doctors provided, setting out detailed restrictions and limitations that would not allow her to perform sedentary work. The court noted these treating doctor’s opinions were not entitled to deference, but were “convincing evidence that her cardiomyopathy, in combination with its effects on her other medical issues, prevented her from performing sedentary work such that she was disabled under the Plan.” Id.

The court then turned to the opinions of the file-reviewing doctors relied on by Unum.  The court noted that 

although there is “nothing inherently objectionable about a file review by a qualified physician in the context of a benefits determination,” Calvertt, 409 F.3d at 296, Haller, Schnars, and Norris’s reports all fail to adequately explain why the medical records they reviewed demonstrate that Mistick is capable of sedentary work; instead, they focus on a critique that the restrictions and limitations recommended by Mistick’s treating physicians are not supported by the medical information contained in her file.

Mistick, at 6.

In further analyzing how Unum’s doctors failed to adequately explain their opinions, the court noted, for example, that Dr. “Schnars’s report views each of Mistick’s health issues in isolation without respect to how her cardiomyopathy affects her other health issues. Such ‘piecemealed medical opinions’ fail to assess Mistick’s condition from a ‘holistic view,’ and, therefore, fail to adequately explain why she is capable of sedentary work. Id., at 6.

Similarly, the court criticized the report of Unum’s Dr. Norris for “call[ing] into question the opinions of Mistick’s treating physicians, asserting that Mistick’s examinations and diagnostics did not show evidence of [a] severe” dysfunction consistent with level of fatigue and severe shortness of breath that our client reported, or Morris’ opinion that she could perform sedentary work. Id., at 6. 

The court went on to explain that the reasons that all the Unum file-reviewing doctors’ opinions, taken alone and together, did not support Unum’s decision to deny benefits is that “each of Unum’s file reviewers made credibility determinations and dismissed the opinions of Mistick’s treating physicians and the limitations they imposed as subjective exaggerations without examining Mistick, although Unum was permitted to do so under the Plan.” Id., citing  Bruton, 2020 WL 398539, at 8-9. As a result, the opinions of Unum’s file reviewers are far less persuasive in evaluating whether Mistick was disabled because of her cardiomyopathy and related health issues. Id.

In sum, Unum failed to consider our client’s other health complications, and did not ever have her physically examined by Unum’s file reviewers. Under ERISA, a physician’s credibility determination is “entitled to little weight” when one merely reviews a file rather than performing a physical examination. These file reviewers cherry-picked elements of medical records and did not properly consider subjective complaints from our client. Unum did not provide a thorough enough analysis of our client’s health condition, leading them to deny her benefits on inadequate information. 

After reviewing the case under the de novo standard, the court found that our client met her burden of proving by a preponderance of evidence that she was incapable of sedentary work, rendering her disabled. Thus, the court agreed that Unum incorrectly terminated her benefits. 

The court granted our motion for judgment as a matter of law and entered judgment in our client’s favor. 

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