Dimopoulou v. First Unum Life Insurance

162 F. Supp. 3d 250, 2016 WL 612890
CourtDistrict Court, S.D. New York
DecidedJanuary 26, 2016
Docket1:13-cv-7159
StatusPublished
Cited by2 cases

This text of 162 F. Supp. 3d 250 (Dimopoulou v. First Unum Life Insurance) is published on Counsel Stack Legal Research, covering District Court, S.D. New York primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Dimopoulou v. First Unum Life Insurance, 162 F. Supp. 3d 250, 2016 WL 612890 (S.D.N.Y. 2016).

Opinion

MEMORANDUM & ORDÉR

ANDREW L. CARTER, JR., United States District Judge:

Defendant First Unum Life Insurance Company (“Unum”) denied plaintiffs claim for long-term disability benefits. She then sued under the Employee Retirement Income Security Act (“ERISA”), 29 U.S.C. § 1001 et seq., asking for a declaration that she is entitled to disability coverage and back payments from the date of her claim. Both parties now move for summary judgment. For the reasons set forth below, both parties’ motions are denied and the claim is remanded for further administrative review.

I. BACKGROUND

A. Statement of facts

i.Plaintiffs long-term disability policy

Plaintiff is a policyholder in a long-term disability insurance plan issued by Unum to her employer, Blackstone Administrative Services Partnership, L.P. (“Blackstone”). Rule 56.1 Stmt ¶¶ 3-4, 301. The policy grants Unum discretionary authority to interpret its terms and provisions when determining eligibility for benefits. Id. at ¶ 301.

ii.Policy definition of disability

The policy defines “disability,” in relevant part, as occurring when “Unum determines that: You are limited from performing the material and substantial duties of your regular occupation due to your sickness or injury_” Id. at ¶ 302. “Material and substantial duties” are those that “are normally required for the performance of your regular occupation.” Id. A “regular occupation” is “the occupation you are routinely performing when your disability begins ... [and] 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.” Id.

iii.Plaintiffs disability claims before Unum

1. July 27, 2010 grant of February 2010 Claim

In February 2010, plaintiff took a leave of absence from Blackstone. Id. at ¶ 64. On February 17, 2010, she filed a Notice and Proof of Claim for Disability Benefits (“February 2010 Claim”), requesting long-term disability benefits from the date of February 1, 2010. Id. at ¶¶ 303-04.

In June 2010, plaintiff returned to work part-time. Id. at ¶ 93. On July 27, 2010, Unum informed plaintiff by letter that it had granted her February 2010 Claim for long-term disability benefits up to the day that she returned to work in June 2010. Id. at ¶¶ 331, 335-36. Unum’s reasoning for the grant was terse. The letter states only that the decision was based on “a combination of your physical and psychiatric conditions.” Administrative Record (“AR”) at 356. No specific condition is identified. The letter also noted that plaintiffs acupuncturist “has indicated that your pain and fatigue are worse when you feel stressed and better after a visit with your therapist. With that in mind, the Mental and Nervous Limitation in your employer’s policy may apply to this and any future claims.” Id.

2. July 21, 2011 denial of November 2010 Claim

On December 7, 2010 a Blackstone representative informed Unum that plaintiff had stopped working again due to her disability. Rule 56.1 Stmt, at ¶ 338. On December 13, 2010, plaintiffs physician, Dr. Ward Carpenter, wrote to Unum in support of plaintiffs renewed claim for [255]*255long-term disability benefits beginning November 30, 2010 (“November 2010 Claim”). Id. at ¶ 149. Dr. Carpenter’s letter stated that he had diagnosed plaintiff with chronic fatigue syndrome (“CFS”) and fibro-myalgia. AR at 411.

On July 21, 2011, Unum informed plaintiff by letter that it had denied her November 2010 Claim for benefits. Rule 56.1 Stmt. ¶ 413. The July 21 letter states that payment for plaintiffs February 2010 Claim had been “made utilizing the policy’s Mental Illness Limitation.” AR at 762. In a section titled “Information That Supports Our Decision,” the letter discusses evidence as to whether the plaintiff suffers from four ailments: depression, bipolar disorder, CFS, and fibromyalgia. Id. at 762-64. In favor of a finding of depression, the letter notes that plaintiff began taking an antidepressant in July 2009, switched to a different antidepressant in November 2010, and upped her dosage on the same antidepressant in December 2010. Id. 762-63. In favor of a finding of bipolar disorder, the letter notes that plaintiffs psychiatrist submitted a psychiatric assessment form to Unum in June 2010 that supported that her bipolar disorder was impairing, given her trouble with focusing and concentration. Id. at 762. It also cites evidence of plaintiffs change in mood and increasing fatigue. Id. at 763.

Against a finding of CFS, the letter states that plaintiffs “signs and symptoms do not meet the CDC [Center for Disease Control and Prevention] diagnostic criteria for” CFS. Id. The letter lists those criteria as “(1) clinically evaluated and unexplained persistent or relapsing chronic fatigue that is new onset, is not a result of ongoing exertion, is not substantially alleviated by rest[,] and results in substantial reduction in previous levels of occupational, educational, social[,] or personal activities” and “(2) the concurrent occurrence of four or more [of] the following symptoms: Substantial impairment in short-term memory or concentration; sore throat; tender lymph nodes; muscle pain; multi-joint pain without swelling or redness; headaches of a new type, pattern[,] or severity; unrefreshing sleep and post[-]exertional malaise lasting more than 24 hours.” Id. The letter notes that CFS is a diagnosis of exclusion, meaning the patient’s symptoms are not explainable by diagnoses of other physical or psychological ailments. Id.

According to the letter, plaintiff failed to meet either of the CFS diagnostic criteria. She failed to meet the first prong because her “fatigue symptoms were clinically evaluated with testing without a medically reasonable explanation of fatigue beyond Depression.” Id. That conclusion is supported by unspecified reports of her psychiatrist from February through June 2010 and plaintiffs prior diagnosis of bipolar disorder. Id. Plaintiff failed to meet the second diagnostic prong of CFS because there were no signs that she suffered from tender lymph nodes, a change in headache pattern (beyond an isolated bout of sinusitis), or post-exertional malaise lasting more than 24 hours. Id. On that final point, the letter cites a notation from a visit with a physician on December 6, 2010 that stated that plaintiff recently felt better after a two-mile run. Id. The letter does note, however, plaintiffs proof of a sore throat on one occasion and muscle and joint pain. Id.

The letter also lays out diagnostic criteria for fibromyalgia as set by the American College of Rheumatology: “a widespread pain index of greater than 7, symptoms present for [at] least 3 months, and not having a disorder that otherwise would explain the pain.” Id. at 764. After briefly discussing plaintiffs symptoms that are congruent with a diagnosis of fibromyalgia, the letter states that those same symptoms overlap with a diagnosis of depression. Id. [256]

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162 F. Supp. 3d 250, 2016 WL 612890, Counsel Stack Legal Research, https://law.counselstack.com/opinion/dimopoulou-v-first-unum-life-insurance-nysd-2016.