Proctor v. Unum Life Insurance Company of America

Background

Tracy Proctor was covered through her employer, LTCG, by a long-term disability plan governed by the Employee Retirement Income Security Act (ERISA). Unum Life Insurance Company of America administered the plan. After Proctor was injured in a February 26, 2018 car accident, Unum approved long-term disability benefits beginning August 27, 2018.

The policy first treated a claimant as disabled when an injury or illness limited the material and substantial duties of the claimant’s regular occupation and caused at least a 20 percent loss in indexed monthly earnings. After 24 months of payments, the policy used a broader standard: whether the claimant could perform any gainful occupation for which she was reasonably fitted by education, training, or experience.

Unum terminated Proctor’s benefits on January 29, 2020, concluding that she could perform her prior occupation full-time. Unum later denied her administrative appeal. Proctor sued under ERISA and sought reinstatement of her benefits. The parties filed cross-motions for judgment on the administrative record and agreed that the court would review the dispute independently, without deference to Unum’s decision.

Court’s analysis

The court held that the policy required an individualized assessment of Proctor’s limitations, not an assessment based on how a typical person with a similar injury would be expected to recover. The court also held that the policy allowed the combined effect of multiple limitations to establish disability, even if no single symptom alone was disabling.

The court found, by a preponderance of the evidence, that Proctor remained disabled under the regular-occupation standard as of January 29, 2020. The record showed continuing cognitive problems, headaches, dizziness, sensitivity to light and screens, difficulty reading and using a computer, and visual limitations. The court found Proctor’s reports generally credible, noting that she consistently reported similar symptoms, in-person providers did not question her reliability, and other evidence supported her reports.

The court rejected Unum’s reliance on the usual recovery pattern for mild concussions and on Proctor’s volunteer activities. It found that her volunteer work, performed at her own pace for short periods, did not show that she could perform the duties of her prior occupation, which included constant keyboard use, visual tasks, concentration, and influencing and making judgments involving other people. The court also noted that no medical professional who personally examined Proctor had cleared her for full-time work or for work in her previous occupation, while Unum’s contrary reviewers had relied on paper reviews.

The court did not decide whether Proctor was disabled under the policy’s later “any gainful occupation” standard. It remanded that question to Unum for an initial determination. The court concluded that benefits should continue until Unum determines that Proctor is not disabled under that standard or the policy otherwise permits termination.

Attorney fees and prejudgment interest

The court awarded Proctor reasonable attorney fees and costs because Unum’s explanation was inconsistent with the policy’s individualized approach and did not adequately explain why its paper reviews were more reliable than the evaluations by Proctor’s in-person providers. The court required additional evidence before setting the amount.

The court also awarded prejudgment interest, finding no exceptional or unusual circumstances that would make the award unfair. It did not decide the interest amount or rate and ordered further briefing and calculations.

Disposition

The court denied Unum’s motion for judgment on the administrative record and granted Proctor’s motion. It ordered Unum to pay all unpaid long-term disability benefits from the termination date to the present, in an amount to be determined; resume benefits until the applicable policy condition permits termination or Unum determines that Proctor is not disabled under the “any gainful occupation” standard; and pay Proctor reasonable attorney fees, costs, and prejudgment interest. The parties were ordered to meet and confer about the amounts and to submit additional filings if they could not agree.