Note: We did not handle this particular claim, but it is summarized here to give an understanding of how federal courts handle long term disability ERISA claims.
Lori Olah, a clinical research associate at Pharmaceutical Product Development, LLC, had surgery on May 2, 2017, to correct a pinched nerve root in her lower back. Post-surgery, she received short-term disability benefits. Dr. Curlee was her orthopedic surgeon. Following her Dr. Curlee’s recommendation, she applied for and received long-term disability (LTD) benefits from Unum Life Insurance Company starting October 29, 2017.
Over the course of her recovery, it appears that significant medical improvements were noted. Her motor strength improved, her endurance increased, and her medication use decreased. By March 2018, Dr. Curlee’s notes indicated that she might be capable of sedentary work. Unum reviewed her case through several medical professionals, including Dr. Tony Smith and Dr. Frank Kanovsky, who both initially found inconsistencies in the need for ongoing disability benefits based on her recovery progress.
Despite Dr. Curlee’s continued support for Olah’s disability claim, Dr. Smith, and later Dr. Kanovsky, after reassessment, concluded that her condition had improved sufficiently to perform sedentary work. By May 15, 2018, Unum terminated her LTD and life insurance without premiums (LWOP) benefits based on these assessments.
Olah appealed this termination, providing additional medical evidence, including an MRI. However, Unum’s third reviewer, Dr. Wade Penny, supported the termination decision, noting improvements in her physical condition that were inconsistent with continued disability claims. The prior decision was upheld, concluding that she could engage in sedentary work and that she did not qualify for continued LTD benefits.
In April 2019, Olah filed suit in the Eastern District of Tennessee. The court’s analysis focused heavily on the medical evidence and expert opinions presented by both parties. The court employed an arbitrary-and-capricious standard to review Unum’s decision to terminate her disability benefits, meaning they evaluated whether Unum’s decision was based on a reasoned and principled process supported by the evidence.
Key Points in the Court’s Analysis
- Medical Improvement Evidence: The court considered the entirety of Olah’s medical records, noting significant improvements in her condition post-surgery. These improvements included increased motor strength, greater walking endurance, and reduced pain medication usage, which were inconsistent with continuing total disability.
- Expert Opinions: Several reviews by medical experts, including Dr. Tony Smith and Dr. Frank Kanovsky, were pivotal. These experts initially supported the continuation of benefits, but eventually concluded that Olah’s recovery allowed for sedentary work. This shift was based on updated and consistent medical evaluations, particularly noting that physical examinations did not support the ongoing severe restrictions claimed.
- Quality of Medical Evidence: The court scrutinized the quality and consistency of the medical evidence provided. Dr. Kanovsky’s and Dr. Smith’s opinions were found to be more aligned with the objective medical evidence that suggested improvement, rather than Dr. Curlee’s assessments, which were viewed as less supported by the medical tests and imaging studies.
- Conflict of Interest: Olah raised concerns about potential conflicts of interest because of Unum’s dual role as both insurer and administrator. However, the court found no substantial evidence that these conflicts influenced the specific decision-making process in her case.
Court’s Decision
The court concluded that Unum’s decision to terminate Olah’s LTD benefits was not arbitrary and capricious. It was deemed a well-supported decision grounded in a comprehensive review of the medical evidence and expert analyzes. The court upheld Unum’s termination of benefits, ruling that the claimant did not meet the plan’s criteria for continued disability under the observed improvements and the capacity for sedentary work.
For individuals dealing with similar challenges in securing or keeping disability benefits, it is crucial to understand that the outcome often hinges on the ability to present comprehensive and consistent medical evidence that aligns with claimed disabilities. Legal support, such as that provided by the Ortiz Law Firm, can be vital in effectively navigating these complex issues and ensuring that all relevant medical improvements or deteriorations are accurately represented and advocated in any disputes over disability benefits. Call (888) 321-8131 for a free case evaluation.
Here is a PDF copy of the decision: Olah v. Unum