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Finding that Insured Was Not Disabled Because He Could Work with Accommodations Was Not Abuse of Discretion

Finding that Insured Was Not Disabled Because He Could Work with Accommodations Was Not Abuse of Discretion

Miller v. Unum Life Ins. Co. of Am., No. 1:12-cv-02956-TCB (N.D. Ga. Jan. 23, 2014)


ERISA and Life Insurance News
(May 30, 2014)

Miller worked for Turner Broadcasting Systems as a maintenance engineer, which was a “medium” level occupation. The material duties of his job included analyzing and troubleshooting computer servers, routers, and other equipment, and responding to maintenance calls.

While receiving short-term and long-term disability benefits under an ERISA plan for a leg abscess and depression, which eventually resolved, Miller was involved in an automobile accident. After the accident, he claimed he could not work due to low back and neck pain.

During the claim evaluation and the administrative appeal, Unum had the file reviewed by three in-house physicians. They concluded that there were no neurological, orthopedic, or other conditions that would prevent Miller from performing his regular medium-duty occupation. The reviewing neurosurgeon opined that Miller could return to work “with accommodation to prevent repetitive lifting and bending.” Ultimately, Unum determined that Miller was able to perform his “regular occupation.”

Unum moved for judgment on the administrative record under Fed.R.Civ.P. 52. Applying the first step of the Eleventh Circuit framework for reviewing ERISA benefits decisions under the arbitrary and capricious standard of review, as set forth in Blankenship v. Metropolitan Life Insurance Company, 644 F.3d 1350, 1354 (11th Cir. 2011), the district court determined that Unum’s claim decision was de novo “wrong” (i.e., the court disagreed with the decision).

However, because Unum was vested with discretion when reviewing claims, the district court’s inquiry proceeded to the next steps to determine whether reasonable grounds supported the decision. Relying on the “binding precedent” of Blankenship, the district court found that the claim decision was not unreasonable, stating:

Here, Unum’s actions mirror MetLife’s. It considered the opinions of Miller’s physicians, but gave them less weight than the opinions of its own physician-reviewers. Each reviewer was convinced that Miller’s complaints of pain and diminished physical capacity were not supported by evidence of physical deficits or abnormalities .... And these opinions were not totally baseless or unfounded. Miller’s own treating physicians, despite their beliefs that his pain was genuine and that he was disabled, never identified explanatory physical abnormalities ....Under Blankenship, it was not arbitrary and capricious for Unum to credit the opinions of its own reviewing physicians and not the contrasting opinions of Miller’s treating physicians.

In so holding, the district court rejected Miller’s argument that the decision was unreasonable because the policy required only that he be disabled from his occupation, without regard to whether he could perform his occupation with accommodations. However, the district court concluded: “Miller misreads the policy. It requires a showing that he is unable to perform the ‘material and substantial duties’ of his occupation and defines those duties as those that ‘cannot be reasonably omitted or modified.’ Denying benefits based on [the physician reviewer’s] opinion – no matter that the Court finds it de novo wrong – was not unreasonable because the policy permitted accommodations.”

The district court also found unpersuasive Miller’s argument that Unum acted unreasonably because it “argued to one branch of the federal government [i.e., the SSA] that Miller was disabled ... and then turn[ed] around and argu[ed] to this Court that he is not disabled.” Distinguishing Metropolitan Life Insurance Company v. Glenn, 554 U.S. 105 (2008), the district court noted that the SSA concluded in that case that the insured was disabled, but that MetLife ignored that conclusion and denied benefits, finding that she was not disabled. In Miller’s case, however, the SSA denied Miller’s request for disability benefits.

Finally, the district court determined that “Miller’s allegations that Unum suffered a case-specific conflict of interest are merely unsupported accusations, and a general conflict of interest – both deciding and paying claims – is not enough to deem its denial arbitrary and capricious.” Rather, “the record shows that several layers of Unum doctors and benefits specialists reviewed Miller’s file and came to the same conclusion: he was not disabled.”

Click here to view the full May 2014 Edition of the ERISA and Life Insurance News.

Authors
H. Sanders Carter
T (404) 962-1015
F (404) 962-1220
Kenton J. Coppage
T (404) 962-1065
F (404) 962-1256
Dorothy H. Cornwell
T (404) 962-1096
F (404) 962-1246
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