Unum Terminates LTD Claim For Facilities Technician Suffering From A Back Injury

The case of Harmon v. Unum Life Ins. Co. of Am. involves plaintiff Joey Harmon against Unum Life Insurance Company of America regarding a claim for long-term disability (LTD) insurance benefits. Mr. Harmon was a facilities technician for 24 Hour Fitness. He suffered a back injury leading to surgery and claimed LTD benefits under policies provided by Unum.

Mr. Harmon received LTD benefits for several years before Unum eventually terminated the claim. The claim was terminated based on Unum’s evaluation of the medical evidence and definitions within the policy regarding disability and the ability to work. Specifically, Unum determined that Mr. Harmon could “perform the duties of other gainful occupations” and was “not disabled under the policy.”

Unum relied on a clinical analysis conducted by a Clinical Consultant Nurse, the Plaintiff’s “reported daily activities,” a vocational review of the Plaintiff’s file, and the Social Security Administrative Law Judge’s denial of Social Security disability benefits in reaching this decision. Unum terminated the claim because Plaintiff’s medical records and self-reported activity level were purportedly “consistent” with full-time, light, functional capacity, and the vocational review “identified occupations” the Plaintiff could “perform that are consistent with gainful occupations” and “do not exceed his functional capacity.”

Mr. Harmon appealed Unum’s denial. The internal appeal process involved a comprehensive review of Mr. Harmon’s medical records, additional assessments by healthcare professionals, and a vocational analysis to determine whether the initial denial aligned with the policy terms and the available evidence.

Unum ordered an additional clinical analysis conducted by a physician board-certified in internal medicine, who concluded that “based on the weight of the medical evidence submitted, there is no physiologic evidence to support ongoing impairment which would support inability to perform” the functional requirements of “occasional lifting up to 20 pounds, frequently up to 10 pounds; frequent sitting with occasional standing, walking with ability to make positional changes.”

Unum upheld its decision to terminate Mr. Harmon’s claim, citing the opinions of the reviewing physicians, the SSA ALJ’s decision that Plaintiff did not qualify as “disabled” under Social Security’s rules, and a substantial gap in the claimant’s treatment.

The claimant thereafter filed a lawsuit against Unum.

The plaintiff presented various reasons to argue that Unum’s denial of benefits was “arbitrary and capricious.” These arguments can be grouped into three main categories:

• First, the plaintiff questioned the validity of Unum’s medical assessment during the appeal process. He argued that Unum based its decision on the opinions of internal staff, who were not specialized in orthopedics, while disregarding the input of the plaintiff’s doctors.
• Second, the plaintiff contested Unum’s assessment of his ability to work, highlighting inconsistencies in Unum’s vocational analysis and a mismatch between the job offered and the policy requirements.
• Lastly, the plaintiff claimed a conflict of interest regarding the defendant that the Plaintiff argued influenced the unjust termination of his benefits, supported by extensive documentation dating back to 2004.

The Court then specifically addressed each category:

• As for the first argument, the Court ruled that Unum’s evaluation of the medical evidence was reasonable, stating, “Unum’s reliance on its medical professionals’ evaluations does not weigh in favor of finding that Unum’s decision to terminate Plaintiff’s claims was arbitrary and capricious.”
• Second, the Court found that Unum’s vocational analysis was not flawed. Although there were errors, the court concluded that Unum’s evaluation and determination did not amount to being arbitrary and capricious.
• Finally, the Court ruled that Defendant’s conflict of interest does not weigh in favor of a conclusion that the decision to terminate the claim was arbitrary and capricious. Plaintiff failed to provide “significant evidence that the use of in-house medical professional reviewers affected Unum’s decision to terminate Plaintiff’s benefits.”

The court ultimately found that none of the arguments, whether considered individually or together, proved that Unum’s decision to deny benefits was arbitrary and capricious. Despite Mr. Harmon’s statements regarding his disability and inability to work, the court upheld the insurer’s decision to terminate LTD benefits because it resulted from “a deliberate, principled reasoning process” and was “supported by substantial evidence.”