Perez v. Unum Life Insurance Company Of America

Background

Robert Perez sued Unum Life Insurance Company of America over the denial of continued long-term disability benefits under a group policy issued to Omnicell, Inc., Perez’s former employer. The policy initially defined disability by reference to the claimant’s usual occupation. After benefits had been paid for 24 months, the policy defined disability as the inability to engage with reasonable continuity in any occupation the claimant could reasonably be expected to perform satisfactorily, considering factors including age, education, training, experience, station in life, and physical and mental capacity.

Perez stopped working after a left knee replacement and right ankle surgery in 2013. Unum approved long-term disability benefits beginning in January 2014 and continued paying them after the policy’s definition changed to the “any occupation” standard. In 2020, Unum obtained medical and vocational reviews. A physical-medicine physician, Dr. Kaisler-Meza, examined Perez and concluded that he could perform sedentary work with restrictions, including lifting or carrying up to 10 pounds occasionally, sitting for 30 minutes at a time followed by a 10-to-15-minute standing or walking break, and avoiding certain bending, kneeling, climbing, and pivoting activities. Vocational reviewers identified Repair Order Clerk, Vehicle Maintenance Scheduler, and Dispatcher as occupations Perez could reasonably be expected to perform. Unum discontinued benefits effective August 21, 2020 and upheld that decision on appeal.

Issues and arguments

Perez moved for judgment that he remained unable to work in any occupation as of August 21, 2020. He argued that the policy’s “any occupation” definition was ambiguous, that the identified jobs were too demanding or unsuitable, that he lacked the necessary computer skills, that the jobs required training or accommodations, and that the independent medical examination should not be considered because it differed from an internal draft report. He also argued that Unum breached its fiduciary duty by failing to provide evidence considered on appeal and by relying on Dr. Kaisler-Meza’s examination.

The parties agreed that the court would review the benefits issue de novo, meaning the court independently determined whether Perez proved his entitlement to benefits rather than deferring to Unum’s decision. The court explained that Perez bore the burden of proving by a preponderance of the evidence that he remained disabled under the policy. Unum therefore was not required to prove that Perez’s condition had changed before ending benefits.

Ruling

The court concluded that Perez had not shown that he remained disabled under the policy as of August 21, 2020. It relied on records showing that his knees and ankle had healed after surgery, that he had increased his activities, that medical treatment for his orthopedic conditions had become infrequent, and that examinations generally did not document disabling strength, motor, sensory, or gait problems. The court also found that Perez’s reported pain was not supported by ongoing treatment or medical evidence that would prevent sedentary work. It found Dr. Kaisler-Meza’s examination and opinions well-reasoned and consistent with other reviews in the record.

The court rejected Perez’s challenges to the alternative occupations. It held that the policy allowed consideration of jobs Perez could reasonably be expected to perform and did not require that he already be qualified to perform them without learning employer-specific software. The vocational evidence stated that no special training, licenses, or certifications were required and that Perez had relevant coordination, scheduling, supervisory, computer, and repair-related experience. The court also held that the policy contained no wage requirement, although Unum’s vocational review considered a wage level equal to 60 percent of Perez’s prior earnings. The court found that the ability to alternate sitting and standing would not interrupt workflow and was not an accommodation required because of a disability.

The court declined to expand the administrative record with the additional documents Perez offered, finding that the existing record was complete and that the proposed documents were largely irrelevant or duplicative. It also rejected the fiduciary-duty claim, finding that Unum provided Perez the claim file and an opportunity to respond and that Perez had not shown errors in Dr. Kaisler-Meza’s examination or findings. The court denied Perez’s motion for judgment and entered judgment in favor of Defendant.