Insurance companies regularly review the ongoing medical care of their recipients of long-term disability benefits to find evidence of improved health and functional capacity that allows the recipients to return to gainful employment. The insurers look for any signs of discontinued medical care, lack of consistent medication regime, and the slightest improvement in overall health to claim that return to work is warranted. Sometimes, the insurers will even change the method they evaluate a claim and reverse their prior determination of eligibility of benefits based on the same information contained in the recipients’ administrative record.

In the recent case of Iravani v. Unum Life Insurance Company of America, 692 F. Supp. 3d 904 (N.D. Cal. 2023), the Plaintiff suffered from degenerative spinal disease, ongoing migraines, neck pain, and back pain that rendered her incapable to perform the daily tasks of her job. After payments for over a decade, Unum discontinued Plaintiff’s long-term disability benefits. Plaintiff sued Unum for denying her long-term disability claim.

The parties agreed that the “de novo” standard of review applied, under which “the court does not give deference to the claim administrator’s decision, but rather determined in the first instance if the claimant has adequately established that he or she is disabled under the terms of the plan.” Muniz v. Amec Const. Mgmt., Inc., 623 F. 3d 1290, 1295-96 (9th Cir. 2010)

The Plaintiff worked as a cosmetic beauty specialist at Saks Fifth Avenue until June 2010 when she stopped working and submitted a claim for disability benefits under a group insurance long-term disability policy issued by Unum. Plaintiff indicated that she was unable to continue working because of neck pain and migraine headaches. Unum approved her claim and started paying her long-term benefits while requesting updated information from Plaintiff and her doctors annually.

Suddenly, on January 7, 2021, Unum terminated Plaintiff’s benefits with the explanation that Plaintiff could “perform the duties of alternate gainful occupations,” so she was no longer considered disabled. Specifically, Unum contended, “based on the totality of the medical evidence in the file, including the infrequency and the lack of intensity in treatment, that Plaintiff could perform “full-time sedentary or light physical demands”, including occupations such as “Information Sales Representative,” “Hotel Sales Representative,” and “Personnel Scheduler.”

Unum retained two physicians to conduct reviews of the medical file and a new vocational expert, who evaluated Plaintiff’s prior work experience. Unum’s experts provided “paper review” opinions that Plaintiff was no longer eligible for long-term disability benefits and could return to work in job occupations requiring far greater skills than Plaintiff possessed based on her work experience. To justify benefits termination, Unum pointed out that Plaintiff had not had any recent imaging studies, received decreased medical treatment over time for her low back and neck pain, and that she controlled her pain with only over-the-counter medications.

Unum did not perform an independent medical examination of Plaintiff to determine the reasons behind her decreased medical care and changes in the medication regime. Contrary to Unum’s conclusions, Plaintiff’s medical condition never improved. However, Plaintiff had a gap in health insurance coverage that explained her lack of doctors’ visits. She also received marginal benefits over the years from strong pain relief medications and steroid injections which lead her to treat her ongoing disability with conservative measures pursuant to her doctors’ recommendations.

The administrative record showed that Plaintiff received extensive medical care during the years of her disability. Since 2010, Plaintiff received ongoing medical treatments and underwent multiple medical tests. Plaintiff’s 2010 MRI of her cervical spine showed “disc degenerative changes and straightening of the cervical spine” that resulted in the diagnosis of cervicalgia, bilateral upper extremity C6 radiculopathy, cervical spondylosis at C5-C6 and C6-C7, and cervical spinal stenosis at C5-C6, and C6-C7. Plaintiff’s medical treatment plan involved steroid injections, physical therapy sessions, at-home exercise plan, chiropractic sessions, general rest, and the medications of Maxalt and Ibuprofen.

As soon as 2011, Plaintiff’s chiropractor identified restrictions in Plaintiff’s ability to sit, stand, and walk, and diagnosed her with cervical disc syndrome, radicular neuralgia, cervical sprain, thoracic sprain/strain, lumbar sprain/strain, and segmental dysfunction along her spine. The chiropractor concluded that “Plaintiff could only return to work with significant accommodations: no more that 4-6 hours of work per day; no lifting, pushing, or pulling over 5-8 pounds; no bending, stooping, or climbing more that 8-10 times per hour; no squatting or kneeling; and no firm grasping or repeated use of hands.”

Based on the Plaintiff’s diagnoses and work restrictions in 2011, Unum granted Plaintiff’s request for disability benefits. During the next 10 years, Unum performed regular reviews of Plaintiff’s medical records and ongoing medical treatment of her disability. Plaintiff continued to visit her regular physicians and continued taking medications. She received chiropractic care that only provided her with temporary benefits according to her medical files. Unum’s own claim analyst, who performed a review in 2017, concluded that Plaintiff’s “diagnosis and symptoms have not gotten any better in the past year and remained consistent with no improvement in functional capacity.”

Bolstering Plaintiff’s arguments for long-term disability benefits, Plaintiff applied for social security and her case was evaluated by an administrative law judge. In 2018, after a hearing, an administrative law judge found Plaintiff’s medical complaints credible and well supported by the medical evidence. The judge determined that Plaintiff was entitled to social security disability benefits.

Despite the presence of overwhelming medical evidence of Plaintiff’s continued disability and work restrictions, Unum terminated her benefits based on flawed “paper reviews” by Unum’s in-house physicians. In 2020, Dr. Stewart Russell, M.D., without examining Plaintiff, opined that “he did not believe any functional restrictions were warranted based on Plaintiff’s medical records”, and “Plaintiff was only taking Tylenol, which he believed was insufficient to support a finding that her migraines caused any impairments.” A second Unum’s medical officer, James Lewis. M.D, who reviewed Plaintiff’s medical file without examining her, agreed with Dr. Russell’s opinion. Neither of Unum’s in-house physicians addressed Plaintiff’s ongoing medical treatment in the past 10 years, her specific diagnosis, and limitations that administrative Judge Flanagan found based on the medical records, and Plaintiff’s own physicians’ diagnosis and recommendations for treatment. Unum did not interview Plaintiff or any of her medical providers.

Additionally, in 2020, Unum hired a new vocational expert to review Plaintiff’s employment history of a cosmetic beauty specialist selling beauty products, and to provide an opinion of whether Plaintiff had the skills for alternative sedentary occupations that would provide a gainful wage. In contrast to two prior vocational experts’ opinions, Unum’s new expert applied a completely different standard of evaluation to Plaintiff’s file and concluded that Plaintiff had a “supervisory and managerial experience.” Unum argued that it reconsidered its interpretation of Plaintiff’s vocational history and overlooked her significant managerial and supervisory experience.

Despite Unum’s extraordinary efforts to rewrite history by claiming that Plaintiff was miraculously cured from a serious degenerative disease based on conservative medical treatment, and that Plaintiff had managerial experience, Judge Haywood S. Gilliam of the Northern District of California rendered judgment for the Plaintiff and ordered Unum to continue paying long-term disability benefits.

 On September 15, 2023, Judge Gilliam concluded that Plaintiff provided sufficient evidence to establish disability and that she was entitled to continued benefits. In his decision, Judge Gilliam provided the following reasons for his ruling: 1) There is no evidence that any of Plaintiff’s treating physicians ever concluded that Plaintiff’s back or neck pain improved, and have consistently found that Plaintiff’s pain stems from degenerative spinal problems; 2) Since 2010, seven different physicians have diagnosed Plaintiff with cervical and lumbar radiculopathies and spinal stenosis; 3) Throughout the time Unum paid Plaintiff’s benefits-and agreed that she was disabled- Plaintiff’s treatment was conservative, and Plaintiff’s doctors expressly recommended conservative treatment as appropriate for her condition; 4) Unum’s conclusion that Plaintiff had the kind of high-level management skills that would be transferable to a job outside of the retail sale of cosmetics is not supported by the record.

Based on the Court’s ruling in this case, the California district courts will support future disability recipients’ arguments that the lack of more intense treatment of a medical condition does not necessarily mean that the condition has meaningfully improved. If insurers attempt to claim that decreased medical treatment and decreased medications regime translate somehow in curing the medical condition giving rise to the disability, their arguments better be supported by experts’ opinions, preferably who have personally examined the claimant, and based on credible medical evidence in the administrative record. Otherwise, the Courts will give deference to the diagnosis and treatments by the claimant’s personal treating physicians, who are in a far better position to evaluate the claimant’s health and improvement. Moreover, the insurers must avoid the pitfall performing vocational evaluations that attribute skills to a claimant that do not exist based on a claimant’s job experience. We have found that disability insurers regularly mischaracterize job skills in order to reach a conclusion that other occupations exist which a claimant can perform when they evaluate whether a claimant can perform “any occupation” under a disability policy.   Hiring the right disability insurance attorney to find disability insurer’s errors can make all of the difference between winning or losing your case.