Deciding disability benefit cases can be challenging for federal courts, but in Dwyer v. Unum Life Ins. Co. of Am., 2021 WL 2853250 (E.D. Pa. July 8), a federal judge in Pennsylvania was able to cut through the confusion and issue a decisive ruling in favor of the plaintiff.

The plaintiff, Colleen Dwyer, was a double amputee — both of her legs were amputated below her knees in 1998 due to toxic shock syndrome. She also suffered from Meniere’s disease, an inner ear disorder that causes dizziness and balance issues. Despite those challenges, Dwyer was able to work as a project manager until 2018 when, at age 56, her Meniere’s disease worsened and she had to stop working.

Although Dwyer received six months of short-term disability benefits, Unum denied her long-term disability claim. The court adjudicated the matter under the de novo standard of review augmented by specific requirements of the 2004 Regulatory Settlement Agreement (RSA) between Unum, the U.S. Department of Labor, and state insurance regulators, and reinstated benefits.

The specific provisions of the RSA the court deemed relevant were the following:

“Giving significant weight to an attending physician’s (‘AP’) opinion, if the AP is properly licensed and the claimed medical condition falls within the AP’s customary area of practice, unless the AP’s opinion is not well supported by medically acceptable clinical or diagnostic standards and is inconsistent with other substantial evidence in the record. In order for an AP’s opinion to be rejected, the claim file must include specific reasons why the opinion is not well supported by medically acceptable clinical or diagnostic standards and is inconsistent with other substantial evidence in the record.”

In addition, the court found the following RSA provision applicable:

“[G]ive significant weight to evidence of an award of Social Security disability benefits as supporting a finding of disability, unless the Companies have compelling evidence that the decision of the Social Security Administration was (i) founded on an error of law or an abuse of discretion, (ii) inconsistent with the applicable medical evidence, or (iii) inconsistent with the definition of disability contained in the applicable insurance policy.”

Finally, the court examined yet another provision applicable to claimants suffering from multiple disabling conditions:

“When multiple conditions … are present, Company personnel will ensure that all diagnoses and impairments are considered and afforded appropriate weight in developing a coherent view of the claimant’s medical condition, capacity and restrictions/ limitations.”

With those guidelines in mind, the court entered findings of fact and conclusions of law in Dwyer’s favor. The court found Dwyer met her burden of proof based on her treating doctors’ reports, Unum’s failure to consider her Social Security disability award, and because Unum did not assess Dwyer’s impairments in combination with one another.

As to the treating doctors, the court observed:

“Defendant cites to cases where judges express skepticism about the objectivity of treating physicians, assuming loyalty may cloud professional judgment. … If a court were to adopt that view, in fairness it would have to employ similar skepticism in evaluating the opinions of a carrier’s consulting physicians, who by the same logic would owe a duty of loyalty to the party paying them. … Here, given the inherent challenge to Plaintiff as a double amputee and the steps taken by her providers … I am persuaded that the opinions they rendered are credible.”

The court also pointed out the significance of the double amputation:

“While Meniere’s symptoms could be disabling in other circumstances, it is clear here how a disease that leads to dizziness, vertigo, and lack of balance would be physically disabling to someone with these amputations, and how the fear of falling and anxiety surrounding the condition would lead to disabling psychological distress such as that reported here.”

The court also agreed with the plaintiff that Unum analyzed each of the plaintiff’s symptoms separately rather than in combination, and concluded with a four-step explanation as to why the plaintiff qualified for benefits:

“First, the unexpected nature of the symptoms mean that she could routinely be interrupted in the middle of projects. Second, the additional difficulties caused by Plaintiff’s amputations and psychological conditions mean that recovery from an episode can take multiple hours. Third, the only medication that has effectively treated Plaintiff’s physical symptoms leads to drowsiness, sedation, and an inability to manage complex tasks. Fourth, Plaintiff is understandably anxious about and distracted by her vulnerability, including her embarrassment in public settings caused by the nature of some of her symptoms. Accordingly, Plaintiff’s conditions prevent her from performing the duties of her regular occupation.”

The court also explained why it was not persuaded by Unum’s medical and non-medical arguments. For example, the court ridiculed Unum’s argument that the plaintiff’s social media posts showed she took pride in salads and other foods she made by remarking: “I can only agree with Plaintiff’s counsel’s response that proffering this as a reason to deny disability benefits ‘is so patently absurd it nearly does not merit a response.’”

The court thus awarded past-due benefits plus prejudgment interest at the prime rate, and invited the plaintiff to petition for fees.

This ruling begins and ends with an absurd proposition — the fact that the plaintiff was a double amputee who was awarded Social Security disability makes it astonishing that a disability insurer would have even challenged Dwyer’s entitlement to benefits. And it is even more surprising that the defendant would try to defend its decision by pointing to pictures of salads made by the plaintiff posted on social media. Since Dwyer’s regular occupation had nothing to do with salad making, the court easily dismissed that argument.

There were certainly debating points resulting from the plaintiff’s refusal to surrender to her unfortunate circumstances and her efforts to be as active as possible, including serving as a wedding officiant after she ceased working as a project manager. However, the use of the Regulatory Settlement Agreement to buttress the plaintiff’s evidence and undermine Unum’s determination effectively paved the road to victory for the plaintiff.

The original article was published in the Chicago Daily Law Bulletin on July 27, 2021.

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