Abi-Aad v. Unum Grp.
| Decision Date | 07 April 2023 |
| Docket Number | Civil Action 21-CV-11862-AK |
| Parties | DANIEL ABI-AAD, Plaintiff, v. UNUM GROUP, UNUM INSURANCE COMPANY OF AMERICA, Defendant. |
| Court | U.S. District Court — District of Massachusetts |
MEMORANDUM AND ORDER ON CROSS-MOTIONS FOR SUMMARY JUDGMENT
Plaintiff Daniel Abi-Aad (“Abi-Aad”) has filed suit pursuant to Section 502 of the Employee Retirement Income Security Act of 1974 (“ERISA”), 29 U.S.C. § 1132(a)(1)(B), to recover long-term disability (“LTD”) benefits denied by Defendants Unum Group and UNUM Life Insurance Company of America (collectively “Unum”) (Count I). [Dkt. 1]. Abi-Aad also brings an action for attorneys' fees and costs pursuant to 29 U.S.C. Section 1132(g) (Count II). [Id.]. Abi-Aad and Unum have filed cross-motions for summary judgment. [Dkt 28, Dkt. 31]. For the following reasons, Abi-Aad's motion for summary judgment [Dkt. 31] is DENIED and Unum's motion for summary judgment [Dkt. 28] is GRANTED.
Abi-Aad initiated this action seeking judicial review of Unum's decision to deny LTD benefits due to a physical condition. [Dkt. 1]. The parties do not dispute that Unum provided Abi-Aad LTD benefits due to mental illness from March 7, 2018 to March 6, 2020. [Dkt. 34-2 at 222; Dkt. 34-4 at 498-99]. Abi-Aad asserts that when Unum terminated his disability benefits due to mental illness on March 6, 2020, he was eligible for continued LTD benefits because he was simultaneously suffering from a physical disability. [See Dkt. 32 at 2-3 ()].
While Abi-Aad was receiving benefits for his mental illness, one of his treatment providers notified Unum that Abi-Aad had chronic pain, a potential physical disability, on February 3, 2020. [Dkt. 34-4 at 387]. Pursuant to the Policy, Unum conducted multiple medical reviews of his condition. [Dkts. 42-1, 42-2, 42-3, 42-4, 42-5, 42-6]. After one non-physician reviewer and two reviewing physicians independently formed conclusions that Abi-Aad did not meet the definition of disabled, Unum notified Abi-Aad that his benefits reached the maximum benefit period for a mental illness disability and terminated his benefits. [Dkt. 34-4 at 498-501].
On October 16, 2020, Abi-Aad appealed Unum's decision to terminate his LTD benefits and provided additional information, including a Physical Residual Functional Capacity Assessment (“FCE”). [Dkt. 34-5 at 205-10, 254]. Unum first had a physician evaluate whether the additional information should invoke a new review of Abi-Aad's claim or whether Abi-Ad's claim should directly proceed to the appeal process to uphold or reverse Unum's previous decision. [See Dkt. 42-4]. After the physician determined that the additional information Abi-Aad provided should not invoke a new review of his physical disability claim, Unum submitted Abi-Aad's claim to two physicians on appeal and upheld its decision to terminate Abi-Aad's claim. [See Dkts. 42-5, 42-6; see also Dkt. 34-5 at 333-43].
Abi-Aad was covered by an employee benefit plan (“the Policy”) administered by Unum and provided by his former employer, Symbotic LLC Plan (“Symbotic”). [See Dkt. 34 at 4-59]. The Plan is governed by ERISA. [Id. at 51-57]. Unum is the claim administrator and bears the responsibility for paying the disability benefits. [See id. at 33]. Abi-Aad has a Bachelor of Science degree from Notre Dame University in Computer Science, and a master's degree in Computer Science from Tufts University. [Dkt. 34-4 at 106]. Abi-Aad has worked in the computer software and information technology (“IT”) industry for approximately twenty years. [Id. at 101-106]. As Symbotic's Director of Software Quality Assurance since 2015, Abi-Aad's job required “frequent reaching, handling, fingering, [and] keyboard use,” along with hiring, traveling, and building products. [Dkt. 34-3 at 82].
The parties do not dispute the contents of the Policy. The Policy defines “disability” as the following:
You are disabled when Unum [Life] determines that: you are limited from performing the material and substantial duties of your regular occupation due to your sickness or injury; and you have a 20% or more loss in your indexed monthly earnings due to the same sickness or injury. After 24 months of payments, you are disabled when Unum [Life] determines that due to the same sickness or injury, you are unable to perform the duties of any gainful occupation for which you are reasonably fitted by education, training or experience.
The Policy limits LTD benefits for mental illnesses to twenty-four months. [Id. at 38]. The Policy defines “mental illness” as follows:
MENTAL ILLNESS means a psychiatric or psychological condition classified in the Diagnostic and Statistical Manual of Mental Health Disorders (DSM), published by the American Psychiatric Association, most current as of the start of a disability. Such disorders include, but are not limited to, psychotic, emotional or behavioral disorders, or disorders relatable to stress. If the DSM is discontinued or replaced, these disorders will be those classified in the diagnostic manual then used by the American Psychiatric Association as of the start of a disability.
[Id. at 48]. Disability due to mental illness is limited as follows:
[Id. at 38].
If the disability is caused by a mental illness and physical disability, Unum's Benefit Center Claims Manual (“the Claims Manual”) states that an individual may apply a physical limitation concurrently. [Dkt. 43-1 at 14]. The mental illness 24-month limitation does not apply when there is a concurrent physical impairment. [Id. at 13-14]. However, those months where the employee is disabled solely due to a mental illness do count towards the 24-month limitation. [Id. at 14].
Although Abi-Aad does not argue that his 24-month limitation clock for benefits due to mental illness should have been tolled, he does argue that Unum was aware that he had a concurrent physical impairment, and that therefore, his LTD disability benefits should not have ended on March 6, 2020. [Dkt. 32 at 2; Dkt. 43 at 1]. The parties do not dispute that to qualify for continued LTD benefits under the Policy, Abi-Aad must meet the definition of disabled by proving that he was unable to perform the duties of any gainful occupation for which he was reasonably fitted by education, training, or experience due to physical disability, prior to the termination of his benefits for mental illness on March 6, 2020. [Dkt. 29 at 15; Dkt. 32 at 1-2].
After a claimant receives twenty-four months of payment for a disability, Unum life will determine if the claimant is disabled if the same sickness or injury renders the claimant unable to perform the duties of any gainful occupation for which they are reasonably fitted. [Dkt. 34 at 31].
Gainful occupation is defined in the Policy as “an occupation that is or can be expected to provide you with an income within 12 months of your return to work, that exceeds: 80% of your indexed monthly earnings, if you are working: or 60% of your indexed monthly earnings, if you are not working.” [Id. at 46]. Unum evaluates the ability for an employee to perform their own or any occupation in terms of the claimant's specific medical restrictions and limitations and their specific material and substantial occupational duties. [Dkt. 43-1 at 2]. While usage of the Dictionary of Occupational Titles (“DOT”) physical demands (sedentary, light, medium, heavy, and very heavy) and frequency descriptors (occasional, frequent, prolonged and constant) are a starting point to determine a claimant's ability to perform a gainful occupation, they are insufficient as standalone descriptions. [Id.].
To determine the employee's capacity to perform their own occupation or any occupation, claimants must provide further information on their ability to perform the occupation based on physical demands involving movement (e.g., balancing climbing, stooping, fingering, handling, etc.), auditory and visual requirements, environmental hazards, work hazards, equipment usage, and cognitive skills required. [Id. at 2-3]. Unum must consider all the data obtained during the claim evaluation process when making the decisions regarding liability, and internal medical resources may be used to assist with the analysis of the medical information provided. [See Id. at 4-7]. If Unum's medical source reaches a different conclusion, Unum documents the claim file with the differing conclusions and makes peer-to-peer contact through a phone call or letter in an effort to...
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