Case Conclusion Date: 12.03.2008
Practice Area: Employee Benefits
Outcome: Denial of LTD benefits "arbitrary and capricious"
Description: In December 2003, my client, Ms. Key, was injured in a car accident. Ms. Key claimed that she was unable to work after December 9, 2004 and filed a claim for long-term disability benefits under a disability insurance policy issued by UNUM. In the Attending Physician Statement Ms. Key submitted with her claim, her doctor diagnosed Ms. Key with neck and upper back pain and indicated that Ms. Key was unable to work as of December 8, 2004. He also indicated that Ms. Key was restricted from lifting, pushing, pulling and keyboarding on a computer and was limited from lifting, pushing or pulling over 10 pounds. Ms. Key supported her claim for disability with the results of her MRI, the results of an occupational assessment test, the opinions of her treating physicians and her own reports. The Court found "problematic" UNUM's argument that the opinions of Ms. Key's doctors were "conclusory," and the opinions of the doctors it consulted were reasonable. To the contrary, Ms. Key's medical records "painstakingly documented" the many efforts she made over the course of a year to treat her pain: medication, physical therapy, chiropractic care, steroids and ergonomic modifications. None were successful and all the reviewing doctors agreed that surgery was not an option for her. Her pain was aggravated while using a keyboard because of the position in which she was required to hold her head. By the end of the workday, she had "severe posterior headaches." In concluding that Ms. Key could perform her job, neither UNUM nor its doctors identified any problems with the reports of Ms. Key or her treating physicians or identified any other evidence that Ms. Key should provide to support her claim. Instead, they simply said that the symptoms Ms. Key reported were greater than what the objective evidence would suggest. Ms. Key and her doctors explained that sitting in a chair and using a keyboard caused her "severe" pain by the end of the day. Although Dr. Davey wrote that Ms. Key could deal with her pain by "switch[ing]positions" and "stretch[ing] periodically," neither he nor UNUM explained why that would be an adequate accommodation. Even more problematic, this view ignored Ms. Key's year-long attempt to find ways to treat and accommodate her pain, including physical therapy, "an ergonomic evaluation" and "strategies to provide maximal support to Ms. Key in the workplace." In rejecting Ms. Key's claim, UNUM simply disregarded all the unsuccessful efforts Ms. Key made to treat her pain and keep working. It is not reasonable to assume without explanation that simple stretching would be sufficient to permit Ms. Key to work when much more aggressive measures failed to provide her with relief. The Court found other problems with UNUM's decision as well. First, UNUM ignored the vocational evaluation, in which Dr. Porter concluded that Ms. Key was unable to perform even sedentary work, despite a "good effort" she put forward during the evaluation. Finally, the determination by UNUM that Ms. Key could work full time after December 8 but could not work full time from November 8 to December 8, even though the evidence to support both claims was exactly the same, "cannot be squared" said the Court. "This puzzling disparity is enough by itself to conclude that UNUM's decision was arbitrary and capricious" the Court held. The Court agreed with Ms. Key that UNUM's decision terminating benefits was arbitrary and capricious because the administrator had relied on the opinion of a doctor who did not explain the basis for his opinion or why it differed from the opinions of the Ms. Key's treating physicians. UNUM's decision was arbitrary and capricious because it failed to provide a "reasoned explanation" that considered "the relevant factors that encompass the important aspects of the problem."