Published by The Pellegrin Firm June 8, 2020

On May 20, 2020, Judge Eldon Fallon of the U.S. District Court for the Eastern District of Louisiana in New Orleans ruled in a case challenging the denial of short-term and long-term disability benefits. The plaintiff began suffering neurological symptoms, including right hand and right body numbness, as well as dragging of her right foot. She underwent an MRI in January 2015. Following the results of the MRI, she was referred to a Multiple Sclerosis (“MS”) specialist for suspected MS. Her neurological examination was “largely unremarkable,” but the MS specialist, Dr. Bagert, recognized that the MRI was abnormal. On another visit, the plaintiff reported her balance was slowly getting worse, and she was experiencing right-sided weakness. Following a few more tests, Dr. Bagert determined that the plaintiff met the criteria for clinically definite MS on May 13, 2015.

On August 24, 2015, the plaintiff filed a claim for short-term disability (“STD”) benefits, claiming that she could no longer work her job as a property manager due to MS. She specifically asserted issues with balance and gait, as well as an inability to stand for extended periods of time, fatigue, and memory changes. Dr. Bagert submitted an attending physician’s statement dated August 28, 2015, in support of the STD claim. During a September 15, 2015 appointment, Dr. Bagert concluded that the plaintiff’s job was a hinderance to her well-being and recommended that she cease working by September 25, 2015. Dr. Davis, a rheumatologist that Dr. Bagert referred the plaintiff to, also provided a statement noting problems with the plaintiff’s balance, standing for extended periods of time, and fatigue, as well as some memory changes.

Unum sent a letter to the plaintiff denying her STD claim. It claimed that the plaintiff did not meet the definition of “disabled” under its STD policy, specifically stating that the physical exam conducted two weeks before her last day of work and “did not confirm [she] had any difficulty with balance or standing.” Unum did not believe the plaintiff to have any functional loss that would prevent her from performing the duties of her occupation. Plaintiff later submitted her claim for long-term disability (“LTD”) benefits. On June 9, 2016, Unum denied the claim for LTD benefits, concluding that her MS was an excluded “pre-existing condition” under the long-term disability policy.

Upon reviewing the administrative record, the court found overwhelming evidence to support the conclusion that the plaintiff suffers from issues with balance, gait, and other issues due to her MS, rendering her unable to adequately perform the material and substantial duties of a property manager. The court relied in part on the fact that no Unum physicians ever examined the plaintiff in person, nor did Unum speak to a single one of the plaintiff’s treating physicians. The Social Security Administration had also found the plaintiff disabled because of her MS, which although not dispositive, is persuasive. Following an exhaustive review of the administrative record under a de novo standard of review, the Court reinstated the plaintiff’s STD benefits.      

In the case of the plaintiff’s LTD benefits, the Court found that while plaintiff had some symptoms consistent with MS before her diagnosis, there was no evidence the plaintiff definitely had MS during the pre-existing condition look-back period. Also, those symptoms had other potential explanations. The court therefore reversed Unum’s decision and reinstate the plaintiff’s LTD benefits. The case is Bayer v. Unum Life Insurance Company of America, et al., No. CV 18-9702, 2020 WL 2558218 (E.D. La. May 20, 2020) (Judge Eldon E. Fallon).