In this recent case out of the Eastern District of Pennsylvania the court found that Unum had abused its discretion when it failed to consider whether the claimant could do the material and substantial duties of her regular occupation. The case answers a question posed by many claimants: Is the insurance company obligated to consider my job duties when evaluating my claim?
History of Ms. Doe’s disability claim
Ms. Doe was employed as a Validation Engineer for West Pharmaceutical Services when she stopped working in September 2010 due to anxiety and depression. When she filed a claim for Short-term disability benefits under her employer disability plan, Unum approved and paid for the maximum period of 26 weeks. However, Unum did not approve Ms. Doe’s claim for long-term disability benefits and concluded that the medical records did not establish that she was “precluded from the material and substantial duties of her occupation.”
Ms. Doe’s First Appeal
Still unable to work, Ms. Doe was forced to file an appeal of Unum’s LTD denial. During its review, Unum referred Ms. Doe’s files to a psychiatrist, Dr. Brown, who concluded that Ms. Doe’s medical files lacked adequate support for an impairment due to mental illness. At the same time, however, Dr. Brown found there was support for an “occupationally precluding impairment… based on the severity of symptoms and the need to establish an effective treatment regimen.” Dr. Brown’s vague statement was apparently just enough for Unum to pay Ms. Doe benefits for an additional six (6) months.
Relying on Dr. Brown’s assessment, Unum partially reversed its prior decision and paid Ms. Doe LTD benefits. However, after paying benefits for approximately 6 months Unum terminated Mr. Doe’s claim and, relying primarily on Dr. Brown’s analysis, found that Ms. Doe did not have psychiatric work restrictions.
Ms. Doe is forced to appeal another denial
Ms. Doe submitted an appeal of Unum’s decision with additional documentation related to her psychiatric impairment. Interestingly, Unum again referred the matter to Dr. Brown, who found, unsurprisingly, that the new documents failed to show Ms. Doe had work restrictions or limitations beyond the time period for which benefits had already been paid by Unum.
Based primarily on Dr. Brown’s findings, Unum denied Ms. Doe’s appeal and affirmed its previous decision.
Ms. Doe files a lawsuit in federal court
Having exhausted all available appeals, Ms. Doe filed suit in federal court seeking to recover the benefits owed to her. She put forth several arguments, one of which focused in on Dr. Brown’s findings, which he had apparently reached without a description of Ms. Doe’s job duties. Ms. Doe argued that Unum had abused its discretion by failing to consider whether she could perform the material and substantial duties of her validation engineer position at West based on her psychiatric conditions, as required by the Plan language.
In reviewing the record, the court revealed that Unum did not discuss Ms. Doe’s job duties in any of its LTD decisions and failed to provide any information to its consulting doctors about Ms. Doe’s job duties or ask them about her ability to perform such duties.
Unum’s defense and the Court’s conclusion
Unum argued that it had no obligation to consider the job duties because it concluded Ms. Doe had no impairment at all. The court disagreed and found that the policy language still required it to consider whether Ms. Doe could do her job duties.
The record showed that Dr. Brown had not been given any description of Ms. Doe’s job duties and was told simply that the “physical demands” of the job included: exerting up to 20 pounds of force occasionally, and/or up to 10 pounds of force frequently, and/or a negligible amount of force constantly; and occasional standing, walking, depth perception, accommodation, color vision; frequent sitting, reaching.
However, as the court explained, Ms. Doe’s Validation Engineer position involved much more than physical duties. The position involved multiple intellectual, oral, written, social, and organizational duties. According to the court, Unum’s failure to consider these material and substantial duties could not be excused.
Does this case mean that the insurer is always required to consider my job duties?
The court’s decision does not mean that an insurance company is always required to consider your job duties when evaluating your claim. It is important to remember that each claim must be evaluated in light of the particular disability policy at issue. Not all disability policies require an insurer to consider your job duties when evaluating your claim and the policy language may not always be clear. A lawyer experienced in ERISA lawsuits can help interpret your disability policy.
If you have been denied Short Term or Long Term Disability Benefits by Unum or any other insurance provider, please contact the Attorneys at Dell & Schaefer for a free consultation.
More Unum disability claim articles on this page.