?Takeaway: This case highlights the importance of ensuring that disability benefits decisions are rooted in a close reading and application of governing plan documents and claims procedures. Here, the court’s decision was based primarily on Unum’s failure to focus on the disabling symptoms the plaintiff actually experienced, contrary to the policy’s “plain language.” Instead, Unum concluded that because the plaintiff’s symptoms were atypical, they were not real. In so doing, the court concluded that Unum inappropriately deviated from the policy.
The decision also cautions plan administrators to take a holistic rather than academic view of disability claims. The court credited conclusions drawn from in-person examinations over those from paper-only reviews because the claimant’s actual providers were “better position[ed] to evaluate” symptoms than “reviewers who never evaluated her in person.” Because the uncontroverted evidence demonstrated that the plaintiff struggled with written and verbal communication and the use of computer screens, the court found she could not perform a job requiring those things.
?The U.S. District Court for the District of Minnesota ordered the administrator of a long-term disability (LTD) benefits policy to reinstate retroactively a former employee’s benefits and pay her attorney fees, thereby rejecting a decision terminating benefits three years earlier.
The court held that, when the policy required the existence of a “disability” to be evaluated “by focusing entirely on the limitations of the claimant,” the administrator inappropriately focused on “whether the ordinary person with a similar sickness or injury would be disabled or how the typical person progresses after the event precipitating the sickness or injury.” The court also rejected the administrator’s failure to appropriately credit the claimant’s self-reported symptoms and the evaluations of medical providers who personally examined her.
The plaintiff worked as a call center supervisor, which required extensive computer use, reading and typing. After sustaining a concussion in a February 2018 car crash, she developed symptoms including headaches, eye pain, vision problems, dizziness and fatigue, and reported difficulty with short-term memory, concentration, communication and other cognitive functions. Her medical providers validated these reported symptoms, diagnosing her with various visual and cognitive impairments. Her providers did not authorize her to perform any work until November 2018, when she was released to work for only two hours per day on three nonconsecutive workdays per week.
In March 2018, the plaintiff applied for LTD benefits from Unum Life Insurance Co. of America, the administrator of her employer’s LTD policy. After collecting information about her condition and conducting its own review, Unum approved her claim in November 2018.
Unum terminated the plaintiff’s benefits in January 2020, however, concluding that her medical records did “not support the opinions of [her] providers or correlate with the inability to perform” her job duties. Specifically, Unum concluded that her injury did not correspond with the prolonged period of impairment, which was otherwise unsubstantiated by physical findings. Unum likewise denied the plaintiff’s subsequent appeal for similar reasons, explaining that while most people recovered from similar injuries within three months, her symptoms “worsened over time” in a manner “inconsistent with the normal trajectory,” and again, were “self-reported” and uncorroborated.
The plaintiff filed an instant claim under the Employee Retirement Income Security Act (ERISA). The parties filed cross-motions for judgment on the administrative record, stipulating to de novo review.
Ruling for the plaintiff, the court rejected Unum’s rationale that she “is now no longer disabled because she is not improving as one would expect.” The court explained that the plain language of the policy “makes clear that disability is evaluated solely by the claimant’s limitations, not what might be typical or a normal trajectory” and without regard to whether “most people would have shown an improvement.”
The court also rejected Unum’s disregard of the plaintiff’s self-reported symptoms because the policy “specifically allows for self-reported symptoms” as a “primary basis” for a disability determination and Unum had originally relied on the same evidence when granting benefits. The court emphasized that no one who personally examined the plaintiff questioned her credibility, but instead maintained that she remained largely unable to work. Unum’s own claims manual stated that opinions based on in-person examinations should only be rejected when specific explanations are provided, which Unum’s own reviewers—who never examined the plaintiff—failed to do.
Finally, the court held that when the plaintiff’s job required constant keyboard use, visual acuity and depth perception, evidence that she struggled to communicate, type e-mails and work with computer screens rendered her unable to complete her job duties, particularly when accounting for her cognitive deficits and headaches. The court thus concluded that the plaintiff had a disability when Unum terminated her benefits and ordered Unum to reinstate her benefits retroactively unless and until she ceased to have a disability or failed to submit requested proof of her continuing disability. The court also ordered Unum to pay reasonable attorney fees in light of ERISA’s remedial nature and purpose.
Proctor v. Unum Life Insurance Co. of America, D. Minn., No. 20-2472 (Sept. 29, 2022).
Brian W. Sullivan is an attorney in the Philadelphia office of Duane Morris LLP.