Downs v. Unum Life Insurance Company of America

Background

Maureen Downs sought benefits under the Hoag Medical Group Long Term Disability Plan, which Unum insured and administered. The plan required an insured to be continuously disabled for 90 days during an elimination period. For someone of Downs’s age at the onset of disability, the plan allowed up to 12 months of benefits at 60% of monthly pre-disability earnings.

Downs stopped working on February 27, 2020. She had surgery on March 3, 2020. Her claim identified several medical conditions and concerns, including diabetes, asthma, a history of heart attack and cancer, depression, and the risk of severe COVID-19 complications. Her primary-care physician stated that her age, medical conditions, and work as a pediatrician placed her at high risk for COVID-19 complications and recommended limiting patient exposure until the pandemic situation improved.

Unum denied the claim on November 10, 2020. Its physician reviewers concluded that Downs could perform her full-time duties because personal protective equipment and other preventive measures described by the Occupational Safety and Health Administration could reduce the risks. Unum later denied her appeal.

Legal standard and review

The claim arose under Section 502(a)(1)(B) of the Employee Retirement Income Security Act, which allows a plan beneficiary to sue to recover benefits due under the plan. The parties agreed that the court would review the benefit claim de novo, meaning the court would decide for itself whether Downs proved disability rather than defer to Unum’s decision. Downs had the burden to show by a preponderance of the evidence that she was disabled under the plan during the claim period.

The court conducted a record-based proceeding under Federal Rule of Civil Procedure 52. It evaluated the administrative record and made findings of fact and conclusions of law.

Court’s analysis

The court concluded that no controlling authority had expressly resolved whether an existing medical condition that creates a high risk of COVID-19, without otherwise preventing a person from performing the physical tasks of the job, can constitute a disability under a long-term disability policy. It therefore examined the facts and the policy language.

The court found that Downs had several recognized COVID-19 risk factors, including a history of cancer, asthma, diabetes, coronary artery disease with a history of heart attack, and fatty liver disease. She was also 70 when she filed her claim. The court accepted that her concerns were not merely a personal fear or voluntary choice because the early pandemic involved substantial risks, vaccines were unavailable, and her work regularly exposed her to patients who might have COVID-19. Unum’s own physician characterized her exposure risk as high, and the Occupational Safety and Health Administration classified her job as having a very high exposure risk.

The court relied on decisions recognizing that a present medical condition may be disabling when returning to work is likely to cause serious future harm. It distinguished cases involving speculative risks or risks that depended on a person’s voluntary conduct. The court found that Downs’s COVID-19 risk was outside her control and was tied to the actual duties of her occupation.

The court also found important differences between Downs’s work and jobs that could be performed with lower exposure risk or additional screening measures. As a pediatric physician, she had to see patients in order to determine whether they were infected. Avoiding COVID-positive patients would therefore make it impossible to fulfill the obligations of her occupation. Her physician had advised her not to return to work, and Unum did not identify what specific preventive measures or protective equipment would reasonably mitigate her risk in 2020. The court further found that protective equipment would not significantly reduce the combined risk created by her patient exposure and underlying medical conditions.

Downs also argued that she was disabled during the claim period independently of her COVID-19 risk. Because the court found that her underlying medical conditions, the nature of her work, and the COVID-19 risks were sufficient to establish disability, it did not reach that separate argument.

Disposition

The court entered judgment for Downs. The opinion does not state that the court separately ordered a particular dollar amount of benefits. The opinion also notes that the plaintiff’s surname was spelled “Downs” in the caption even though it stated the surname was “Downes.”