Doe v. Unum Life Insurance Co. of America

35 F. Supp. 3d 182, 2014 WL 3893096, 2014 U.S. Dist. LEXIS 110277
CourtDistrict Court, D. Massachusetts
DecidedAugust 8, 2014
DocketCivil Action No. 12-11413-RWZ
StatusPublished
Cited by5 cases

This text of 35 F. Supp. 3d 182 (Doe v. Unum Life Insurance Co. of America) is published on Counsel Stack Legal Research, covering District Court, D. Massachusetts primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Doe v. Unum Life Insurance Co. of America, 35 F. Supp. 3d 182, 2014 WL 3893096, 2014 U.S. Dist. LEXIS 110277 (D. Mass. 2014).

Opinion

MEMORANDUM OF DECISION

ZOBEL, District Judge.

Plaintiff John Doe1 (“Doe”) filed this action against defendants Unum Life Insurance Company of America and Unum Group (“Unum”). He contends that Unum arbitrarily and capriciously denied him long-term disability (“LTD”) benefits in violation of the Employment Retirement Income Security Act of 1974 (“ERISA”), 29 U.S.C. §§ 1001-1461.2 Now pending are the parties’ cross-motions for summary judgment (Docket ## 60, 63). For the following reasons, both motions are DENIED and the case is REMANDED to Unum.

I. Background

A. Plan Language

Doe participated in an employee benefits plan (“the Plan”) which included LTD benefits. The relevant Plan language states,

You are disabled when Unum determines that:

—you are limited from performing the material and substantial duties of your
regular occupation due to your sickness and 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 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^]

Administrative Record3 (“AR”) 375 (emphasis removed). A “regular occupation” is “the occupation you are routinely performing when your disability begins.” Id. 402. A “gainful occupation” is one 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. 399.

The Plan limits lifetime cumulative benefits for disabilities due to mental illness to 24 months. Id. 383. If an individual has exhausted the two years of mental illness-related payments, he or she may continue to received LTD benefits only if he or she is disabled due to physical illness. Id. 966.

B. Doe’s Claim

In 2004, Doe was diagnosed as HIV-positive after complaining of diarrhea and fatigue to his doctor. Id. 1966. After his diagnosis, Doe continued to work as a [186]*186partner in a large accounting firm. In April 2007, Doe attempted suicide by inserting a large amount of crystal methamphetamine into his rectum. Id. 2Ó0-01. After he recovered in the hospital, he attended a residential treatment program in northern' California for nearly three months. Id. 51. Doe sought and received a leave of absence from work during this time. Id. 109-110.

Doe applied for LTD benefits. In its review of his application, Unum noted that Doe was primarily unable to work due to the side effects of his drug abuse, paranoia, and anxiety, especially around computers and other technology. Id. 524. On March 25, 2008, Unum approved his request. Id. 561. The letter alerted Doe to the 24-month maximum payment period for disability due to mental illness. Id. 563. In June 2008, Doe attempted suicide again by overdosing on Ativan pills. Id. 727.

On October 16, 2009, Doe exhausted the 24-month benefit period. He applied for continued benefits due to physical illness. Unum made payments under a reservation of rights while it investigated Doe’s claim. Id. 2918. Its investigation shows the following.

C. Doe’s Physicians

Doe received primary treatment from Dr. Kevin Kapila, an infectious disease expert and internist, and from Dr. Douglas Horst, a gastroenterologist.

1. Dr. Kevin Kapila

Kapila became Doe’s primary care physician in January 2009. Id. 3695. In a February 12, 2009, office visit, Kapila noted that Doe experienced “some fatigue.” Id. 2147. In a March 23, 2009 follow-up, Kapila documented Doe’s “continued problems with GI upset presenting as diarhea [sic] which was his main complaint when he was [diagnosed] with HIV.” Id. 2144. On April 27, 2009, Kapila noted that Doe’s diarrhea continued. Id. 2140. He also suffered a herpes outbreak and was prescribed medication. Id. The next month, Kapila noted that Doe reported a “[problem with controlling his bowels ... [and he] has had accidents when he goes out. He has a lot of cramping prior to the episodes. [He is] [c]areful with his diet, [and] cannot think of a food that triggers it.... Ever[y] [bowel movement] is loose and urgent.” Id. 2127. He further noted that Doe’s “[fjatigue is present, severe at times.” Id. The fatigue had “escalated since the beginning of the year.” Id. The fatigue did not have a clear etiology from the lab tests, but could have been related to Doe’s diarrhea, mood, or the effect of crystal meth relapses on his body. Id. 2129. When he saw Doe in September, Kapila recorded that Doe had a

recurrence of diahrea [sic] over the weekend[.] ... He has had multiple loose and watery [bowel movements] over the weekend[;] also does not feel food is digested[;] seeing undigested food[.] This has been keeping him up at night and his fatigue is much worse[.] He is having some muscle cramps[.] IF [sic] he tries to eat this will trigger nausea[.]

Id. 2327.

The follow-up visits continued, as did Doe’s physical symptoms. In December 2009, Kapila noted that “[d]iarhea [sic] is still [Doe’s] main complaint ... [and it] is causing some isolation^] [he is] no [sic] able to go out due to fears of having and actually having fecal accidents.” Id. 3265. His fatigue was “much worse with increase [sic] diarhea [sic].” Id. The next month, Kapila recorded that Doe’s gastrointestinal biopsies were negative, but his diarrhea still persisted. Id. 3252. He wrote, “basically the way [Doe] deals [with it is] that [187]*187he does not eat[;] if he eats then he has to go, having accidents if he does not plan[;] limits function.” Id. His fatigue remained. Doe “sleeps up to 14 hours in a day.” Id. Kapila stated that Doe “[s]till has a severe level of impairment and can not work.” Id. The diarrhea and fatigue continued through 2010. Id. 3423, 3228-30, 3207, 3194, 3635-36, 3626.

In December 2010, Kapila wrote a letter regarding Doe’s condition to Doe’s attorney. Id. 3695. In it, he stated that Doe has been taking Atripla, a combination an-tiretroviral HIV medication. Id. He mentioned that he referred Doe to Dr. Horst for treatment of his “diarhea [sic] which has been severe, resulting in fecal incontinence,” for which Doe had taken Imodium and probiotics. Id. Kapila noted that diarrhea is a common symptom of HIV-positive individuals, and may be caused by Atripla, antidepressants, or HIV itself. Id. Doe’s fatigue was also “severe.” Id. Kapila concluded,

I do not believe that [Doe] is malingering or obtaining secondary gain from his current condition. He has been very compliant with his treatment and has been proactive in finding any ways to resolve his symptoms.

Free access — add to your briefcase to read the full text and ask questions with AI

Related

Cite This Page — Counsel Stack

Bluebook (online)
35 F. Supp. 3d 182, 2014 WL 3893096, 2014 U.S. Dist. LEXIS 110277, Counsel Stack Legal Research, https://law.counselstack.com/opinion/doe-v-unum-life-insurance-co-of-america-mad-2014.