Kamerer v. Unum Life Ins. Co. of Am.

• Decision Date: 21 September 2018
• Docket Number: CIVIL ACTION NO. 15-CV-40146
• Citation: Kamerer v. Unum Life Ins. Co. of Am., 334 F.Supp.3d 411 (D. Mass. 2018)
• Parties: Judith KAMERER, Plaintiff, v. UNUM LIFE INSURANCE COMPANY OF AMERICA; Provident Life and Accident Insurance Company; and Unum Group, Defendants.
• Court: U.S. District Court — District of Massachusetts

334 F.Supp.3d 411

Judith KAMERER, Plaintiff,

v.UNUM LIFE INSURANCE COMPANY OF AMERICA; Provident Life and Accident Insurance Company; and Unum Group, Defendants.

CIVIL ACTION NO. 15-CV-40146

United States District Court, D. Massachusetts.

Signed September 21, 2018

Jonathan M. Feigenbaum, Boston, MA, Talia Ravis, Pro Hac Vice, Law Office of Talia Ravis, PA, Kansas City, MI, for Plaintiff.

Joseph M. Hamilton, Patrick M. Winn, Mirick O'Connell Demallie & Lougee, Worcester, MA, for Defendants.

ORDER AND MEMORANDUM ON CROSS-MOTIONS FOR SUMMARY JUDGMENT (Docket Nos. 94 & 97)

TIMOTHY S. HILLMAN, DISTRICT JUDGE

Pending before the Court are cross-motions for summary judgment in this action brought under the terms of the Employee Retirement Income Security Act of 1974 (ERISA). For the reasons set forth below, Plaintiff's motion (Docket No. 97) is granted and Defendants' motion (Docket No. 94) is denied. Plaintiff's long-term disability benefits are hereby reinstated and she is to be compensated for past benefits due.

Background

1. Plaintiff's Policies

The Plaintiff, Judith Kamerer, initiated this action seeking judicial review of Unum Life Insurance Company of America ("Unum Life"), Provident Life and Accident Insurance Company ("Provident Life"), and Unum Group's decision to terminate her long-term disability benefits. Plaintiff was covered under two separate policies. The group policy issued by Unum Life (the "LTD Policy") and the individual policy that she purchased to supplement her basic coverage issued by Provident Life (the "IDI Policy"). (Administrative Record Volume I).¹

The LTD Policy defines disability as follows:

You are disabled when Unum determines that:

-you are limited from performing the material and substantial duties of you 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.

You must be under the regular care of a physician in order to be considered disabled. (GRP-PLN-17).

Regular Occupation is defined in the LTD Policy as:

The occupation you are routinely performing when your disability begins. Unum will look at your occupation as it is normally performed in the national economy, instead of how the work tasks are performed for a specific employer or at a specific location. (GRP-PLN-43).

The LTD Policy also states that benefits are no longer payable when any of the following occur:

-when you are able to work in your regular occupation on a part-time basis but you choose not to.

-if you are working and your monthly disability earnings exceed 80% of your indexed monthly earnings, the date your earnings exceed 80%.

-the end of the maximum period of payment;

-the date you are no longer disabled under the terms of the plan, unless you are eligible to receive benefits under Unum's Rehabilitation and Return to Work Assistance program;

-the date you fail to submit proof of continuing disability;

-The date you die. (GRP-PLN-24).

The IDI Policy defines total disability as follows:

Total Disability or Totally Disabled means that because of Injuries or Sickness:

1. You are unable to perform the material and substantial duties of Your Occupation; and

2. You are not engaged in any other occupation; and

3. You are receiving Physician's Care. We will waive this requirement if We receive written proof acceptable to Us that further Physician's Care would be of no benefit to You. (IDI-POL-13)

"Your Occupation" is defined in the IDI Policy as "The occupation or occupations, as performed in the national economy, rather than as performed for a specific employer or in a specific location, in which You are regularly engaged at the time You become Disabled." (IDI-POL-13).

The LTD Policy limits all disabilities due to a mental illness to a cumulative benefit period of 24 months. The LTD Policy defines mental illness as:

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 or to substance abuse or dependency. 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. (GRP-PLN-42).

The IDI Policy states that if the disability is caused by a mental disorder the maximum benefit period is also 24 months over the life of the policy. (IDI-POL-8, 21).

Mental Disorders are defined as follows:

Any disorder (except dementia resulting from stroke, trauma, infections or degenerative diseases such as Alzheimer's disease ) classified in the Diagnostic and Statistical Manual of Mental 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 or to substance abuse or dependency. If the DSM is discontinued or replaced, these disorders will be those classified in the diagnostic manual then in use by the American Psychiatric Association as of the start of a Disability. (IDI-POL-11).

2. Plaintiff's Medical History and the Termination of Benefits

On June 20, 1988, Ms. Kamerer began working at Accenture. (ARIDI at 372). She worked continuously at Accenture until becoming occupationally disabled in January 2004. (ARIDI at 382). Her last position at Accenture was Associate Partner, which paid an annual salary of $155,400. (ARIDI at 3731; ARLTD at 5445). Ms. Kamerer became disabled due to fibromyalgia, inflammatory arthritis, hypothyroid and insomnia, which she contends caused her constant pain in her joints, severe headaches, and "fibro-fog." (ARIDI at 363; 372; 377; 380). She was prescribed numerous medications including OxyContin, Lortab, Actiq, Suboxone, Phenergan, Maxalt, and Zonegran to treat her pain. (ARLTD at 308; 5155; 5158).

Ms. Kamerer concurrently struggled with depression. (ARLTD at 308). In January 2004, Ms. Kamerer reported being depressed over having lost her job and having a child in the hospital. (ARLTD at 308). In February 2004, her arthritis specialist, Dr. Katz, noted that Ms. Kamerer had fibromyalgia and that depression could be playing a role in her condition. (ARLTD at 255). A month later, Dr. Katz noted that Ms. Kamerer's condition was "a classic fibromyalgia picture" but "[a]s is typical with pain syndromes, it has been difficult to establish whether her depression has been primary or secondary." (ARLTD at 167).

In February of 2004, she filed claims for benefits under both policies. (ARIDI at 361-377). On May 10, 2004, Unum approved her claim under both policies. (ARIDI 594-597). In 2008, Ms. Kamerer's claim was assigned to the extended duration unit. (ARIDI at 342-343). Unum paid Ms. Kamerer's benefits uninterrupted for the years 2004-2013. (ARIDI at 2647-2657).

Subsequent to the initial approval of her claim and throughout its administration, Ms. Kamerer was required to submit periodic claimant statements, attending physician statements, and both Unum Life and Provident Life had periodic contact with Ms. Kamerer regarding her condition. (ARLTD at 438-444; 522-526; 879; 968; 1061-1064; 1124). During this time, Ms. Kamerer did provide extensive records to Unum from her treating healthcare providers, principally a neurologist, urologist, and psychologist. (ARIDI at 197- 230; 248; 253; 362; 376; 380; 540-543; 548-549; 561-580; 617-718; 788-808; 814-839; 849; 852-853; 908-921; 923; 928; 940-945; 948-950; 962-964; 977-1083; 1092-1135; 1282-1430; 1432-1580; 1583-1761; 1763-1837; 1857-1865; 1875-1883; 1888-1890; 1909-1953; 1958-1959; 2001-2002; 2073-2086; 2092; 2241-2247; 2255-2256; 2382-2383; 2423-2425; 2439-2440; 2462-2463; 2480-2481; 2494-2495; 2559; 2566-2569; 2590-2593; 2595-2598; 2615-2617; 3271; 3297-3298; ARLTD at 5299-5310).

When her symptoms failed to improve, Ms. Kamerer sought treatment at the Mayo Clinic. (ARIDI at 749-772). Doctors at Mayo also found that Ms. Kamerer had "symptoms and findings ... consistent with the diagnosis of fibromyalgia" and subsequently entered her into the Fibromyalgia Treatment Program. (ARIDI at 755; 759). She also sought treatment at Mayo for her depression. (ARLTD at 353-355). Doctors at Mayo subsequently recommended admission to the Mood Disorder's Unit at Mayo for treatment of her depression. (ARLTD at 354-355).

In July, 2013, Charlene Saucier, a Clinical Consultant, performed a review of Ms. Kamerer's medical history. (ARLTD at 3042-3049). In an interview shortly before that review, Ms. Kamerer told Unum representatives that she was being treated by Dr. John Gamble, Dr. Holly Kaufman, and Dr. Jim Lemons. (ARLTD at 2952-2953). Dr. Gamble gave Ms. Kamerer no work restrictions. (ARLTD 2982-2983). Dr. Kaufman suggested that Unum contact Ms. Kamerer's pain management specialist. (ARLTD at 3000). After Dr. Gamble left his practice, Ms. Kamerer began seeing Dr. Karan Baucom (ARLTD at 3060). Dr. Baucom, who was treating Ms. Kamerer for addiction, did not provide any restrictions on Ms. Kamerer returning to work. (ARLTD at 3087).

On September 6, 2013, Unum notified Ms. Kamerer that her benefits under the LTD Plan would be discontinued after its medical department reviewed her file and determined that she had the functional capacity to return to her job. (ARIDI at 2520-2525; ARLTD at 3220-3225). On September 10, Unum also terminated Ms. Kamerer's benefits under the IDI Plan. (ARIDI at 2521). Unum's vocational review classified Ms. Kamerer's occupation as a Systems Project Manager and an internal medical reviewer concluded that she had the functional capacity to meet the physical demands of that occupation. (ARIDI at 2829). According to the vocational review, the physical demands associated with a Systems Project Manager included,...