Elias v. UNUM Life Insurance Company of America

Background

Bijan Elias was an employee of Applera Corporation and worked as a Field Sales Representative before going on disability leave on June 2, 2008. UNUM Life Insurance Company of America was the insurer and claims administrator for Applera’s employee-benefit plan. The plan was governed by the Employee Retirement Income Security Act of 1974 (ERISA), and it gave UNUM discretionary authority to decide eligibility for benefits.

After receiving short-term disability benefits, Elias was approved for long-term disability benefits based on depression and post-traumatic stress disorder. He was also approved for Social Security Disability benefits. He later developed or was diagnosed with physical conditions, including lower-back and shoulder pain, fibromyalgia, headaches, sleep apnea, and chronic pain.

The plan limited the total lifetime period for disabilities due to mental illness to 24 months. UNUM told Elias that this limit would expire on November 28, 2010, but said it would continue reviewing whether he qualified for benefits based on nonpsychological medical conditions. UNUM continued paying benefits for years, but in 2020 reviewed whether Elias remained unable to perform the duties of his occupation. After reviewing medical records and opinions from consultants, UNUM ended his benefits effective January 6, 2021. UNUM later denied Elias’s administrative appeal.

Elias sued under ERISA, seeking a declaration that he was entitled to ongoing benefits while he remained disabled under the plan. The parties filed cross-motions for summary judgment, asking the court to resolve the claim without a trial.

Legal standard

Because the plan gave UNUM discretionary authority to determine eligibility, the court reviewed UNUM’s decision for abuse of discretion. Under that standard, the court had to uphold the decision if UNUM gave a reasonable explanation supported by substantial evidence. The question was whether a reasonable person could have reached a similar decision, not whether the court would have reached the same decision.

Analysis

Evidence of disability. Elias argued that UNUM ignored evidence such as his reports that he spent much of the day in bed, used a cane, suffered frequent falls, and experienced severe pain. The court concluded that UNUM’s benefits-termination letter considered the medical record as a whole and addressed some of this evidence. UNUM was not required to explain the weight it gave to every piece of evidence. The court found that UNUM reasonably relied on evidence that Elias could live alone, perform household chores, drive, walk several blocks, and had normal physical-examination results, as well as evidence concerning improvement in his pain. The court held that Elias had not shown an abuse of discretion.

Review of the appeal and conflicting medical opinions. Elias argued that UNUM improperly discounted Dr. Sara Rahman’s opinions and relied on an incomplete review by its consultants. The court found that UNUM’s consultants provided detailed analyses based on the medical records and that the record contained conflicting medical opinions. Dr. Rahman initially stated that she had no opinion about Elias’s functional capacity, but later stated that he could not perform the job’s demands. The court held that UNUM was not required to give special deference to Dr. Rahman and had not arbitrarily refused to credit reliable evidence.

The court also rejected Elias’s claim that Dr. Suzanne Benson conducted a selective review. It found that Dr. Benson considered the documented medical visits from 2020 and 2021 and could not assess periods for which Elias had not provided medical records. The court also concluded that UNUM did not misstate the record by relying on Dr. Rahman’s note reporting an 80 percent reduction in bone pain. Dr. Rahman had not revised or corrected that note after Elias later said the improvement was limited to his fingers.

Improvement in condition. Elias argued that UNUM could not end benefits without showing a substantial improvement in his condition. The court distinguished an earlier case because, here, the record included reports of improvement between 2016 and 2021. Those reports included exercising two hours per day, independently performing daily activities, improved bone pain, improved fibromyalgia symptoms, and satisfactory current treatments. The court held that UNUM did not abuse its discretion by failing to identify a different substantial change in symptoms.

Combined effect of medical conditions. Elias argued that UNUM evaluated each condition separately rather than considering their combined effect. The court disagreed. It found that UNUM considered Elias’s overall capacity, including his ability to live alone, shop, and perform household chores. The court also relied on Dr. Benson’s statement that her opinion was based on a “whole person analysis.” It held that UNUM had considered Elias’s total well-being and functional capacity.

Paper review. Elias argued that Dr. Benson’s review was unreasonable because she reviewed the medical file without examining him. The court explained that a physical examination may receive greater weight but is not required in every case. UNUM had obtained reviews from three consultants, each of whom concluded that Elias could perform his job. The court also found that Dr. Rahman’s inconsistent assessments reduced the weight of her later opinion. It held that UNUM’s file review did not constitute an abuse of discretion.

Full and fair review. Elias argued that UNUM denied him a full and fair appeal because it did not give him an opportunity to review and respond to Dr. Benson’s report. The court concluded that the version of the governing regulation in effect before 2018 did not require a plan administrator to provide documents developed or considered during the appeal before issuing its final decision. Because Elias’s initial claim was filed before 2018, the court rejected this argument.

Mental-health limitation. Elias argued that UNUM acted improperly by applying the 24-month mental-health limitation after continuing to pay benefits for more than ten years. The court held that UNUM had told him the limitation would be exhausted in 2010 and that later benefits would be based on nonpsychological conditions. It concluded that the plan’s plain language imposed a lifetime cumulative maximum for disabilities due to mental illness, including claims based on both mental and physical conditions. The court therefore held that UNUM properly applied the limitation.

Alleged claims-administration bias. Elias asked the court to consider UNUM’s alleged history of biased claims administration. The court held that controlling precedent did not treat that history as relevant to claims filed after 2005, and Elias provided no evidence of bias during the period relevant to his claim.

Disposition

The court denied Elias’s motion for summary judgment and granted UNUM’s motion for summary judgment. The order directed that judgment be entered accordingly.

Potential internal inconsistency

One sentence in the full-and-fair-review discussion says, “Accordingly, UNUM’s review of Elias’s claim on appeal did constitute an abuse of discretion.” That sentence conflicts with the surrounding analysis, which rejects Elias’s argument, and with the order’s final rulings granting UNUM summary judgment and denying Elias summary judgment. The summary follows the stated analysis and final order.