Insurance companies often base denials of disability claims on the mere review of the available documentation in the existing claims files.  It is cheaper for them to do so and by using their own paper reviewer, they reduce the risk of an unfavorable report after completion of a significantly more expensive independent medical examination. By carefully selecting the paper reviewers, the insurance companies can obtain some “evidence” of a basis for denial of claim benefits.  But how much value do such reports have, particularly if they conveniently fail to address substantial evidence of disability in the reports of the claimant’s treating physicians in the claims file?

In a recent disability benefits decision involving Unum Life Insurance Company (“Unum”), Rios v. Unum Life Ins. Co., 2020 WL 7311343 (C.D. Cal. Dec. 10, 2020), the court reviewed the denial of a disability claim under a de novo standard of review and determined that the claimant was entitled to disability benefits.

Claimant Yolanda Rios worked as a User Support Specialist for large national law firm, Arnold & Porter Kaye Scholer, L.L.P., until she made a claim for disability benefits with Unum. Claimant’s specific job at Arnold & Porter required constant sitting as well as intense concentration and logical thinking. Her Regular or Usual Occupation in the national economy required “constantly sitting” for more than 5.5 hours in an 8-hour day, and it required “focus and concentration.”  Rio’s primary disabling condition was “back and leg pain (sciatica) related to multi-level degenerative lumbar disc disease, stenosis, radiculopathy, and ‘severe disc narrowing at L4/5.’”  Unum initially approved and paid long-term disability benefits based only on her anxiety and depression and not on any physical impairment, but Unum agreed to further evaluate her physical complaints.

Unum based its denial on a “paper review” of the records which arbitrarily failed to adequately address the claimant’s own testimony regarding pain.  The medical reviewer ignored substantial evidence of “excess pain” throughout the claimant’s medical records.  Unum had the opportunity to medically examine the claimant and chose not to do so while knowing of the evidence of Rio’s significant pain in the medical records.  The court’s disability finding was further supported by the Social Security Administration’s determination that the claimant was “less than sedentary” and, therefore, disabled from “any gainful occupation.”  Although the favorable SSA ruling was not dispositive, the court, following applicable Ninth Circuit precedent, found it to be relevant.

The Rios court criticized Unum’s paper review because it conflicted with substantially all the medical evidence, and it faulted Unum for failing to conduct a medical examination of the claimant.  The court held that Rios was disabled under both the “own” and “any” occupation standards and faulted Unum’s reviewer for numerous misstatements and inaccuracies.  It noted that at least five treating doctors or health care providers had documented that she was taking drugs that affected her concentration, that she had memory problems and that her muscle relaxant did not allow her to work.  Because her current job required the ability to focus on a task for some length of time and the ability to use reasoning consistently in her regular and usual occupation as required in the national economy, Rios was disabled under both standards.

The court found that Unum arbitrarily discredited Rios’ testimony of her pain, and her testimony was supported extensively in the medical records. And, Unum did not bother to conduct its own medical examination of the claimant.  Unum’s failure to do so “‘raise[s] questions about the thoroughness and accuracy’ of its benefits determination.”  Rios, 2020 WL 7311343, at *3, citing Montour v. Hartford Life & Acc. Ins. Co., 588 F.3d 623, 630, 634 (9th Cir. 2009). The court was skeptical of the opinions of Unum’s non-examining experts because it found that the opinions of the examining physicians were “entirely one sided in favor of [Plaintiff’s] claim.”  Rios, 2020 WL 7311343, at *3, citing Salomaa v. Honda Long Term Disability Plan, 642 F.3d 666, 676-679 (9th Cir. 2011).

Rios is instructive in demonstrating the relative lack of evidentiary value a court should attribute to such one-sided paper reviews. The ruling recognizes that the insurer had the opportunity to obtain better evidence of the actual current condition of the claimant through a medical examination, and that the insurer should not benefit from its failure to engage in such examination. And, of course, one-sided paper reviews that completely fail to consider abundant evidence of disability are entitled to little, if any, consideration.  In addition, Rios underscores the need for claimants to supplement the evidence in the claim file with additional favorable evidence. In particular, Ms. Rios benefited from the supplementation of the record to include the approval of her SSA benefits, which approval occurred after her claim was submitted and was, therefore, not available for consideration at the time of the insurance company’s denial of benefits.

The involvement of skilled ERISA attorneys can make an important difference in the likelihood of a favorable outcome in these matters. McKennon Law Group PC focuses its practice on assuring the most favorable presentation of such reasonably available evidence to the court and the opposing party. Its expertise in handling these matters can be seen in the numerous rulings in favor of claimants.  If you believe that an insurance company or benefits administrator has unfairly handled your claim for disability benefits, we urge you to contact us for a free, no-obligation, case evaluation.  Let us see what we may be able to do to help you get the benefits you deserve.