Downs v. Unum Life Insurance Company of America

CourtDistrict Court, N.D. California
DecidedAugust 19, 2024
Docket3:23-cv-01643
StatusUnknown

This text of Downs v. Unum Life Insurance Company of America (Downs v. Unum Life Insurance Company of America) is published on Counsel Stack Legal Research, covering District Court, N.D. California primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Downs v. Unum Life Insurance Company of America, (N.D. Cal. 2024).

Opinion

1 2 3 4 5 6 7 UNITED STATES DISTRICT COURT 8 NORTHERN DISTRICT OF CALIFORNIA 9 MAUREEN DOWNS, 10 Case No. 23-cv-01643-RS Plaintiff, 11 v. ORDER ON MOTIONS FOR 12 JUDGMENT UNUM LIFE INSURANCE COMPANY 13 OF AMERICA, 14 Defendant. 15 I. INTRODUCTION 16 Plaintiff Maureen Downes (erroneously spelled “Maureen Downs” in the caption of this 17 matter) has brought this action against defendant Unum Life Insurance Company of America 18 (“Unum”) pursuant to Section 502(a)(1)(B) of the Employee Retirement Income Security Act 19 (“E.R.I.S.A.”), 29 U.S.C. § 1132(a)(1)(B). Plaintiff seeks benefits under the Hoag Medical Group 20 Long Term Disability Plan (“the Plan”) which is insured and administered by Unum pursuant to a 21 group long-term disability policy (“the Policy”). 22 A record-review proceeding took place pursuant to Federal Rule of Civil Procedure 52 in 23 August of 2024, during which the parties’ cross-motions for judgment based on the Administrative 24 Record (AR) were heard. Pursuant to the facts adduced at that hearing, the parties’ briefing, and in 25 the AR, judgment is entered for the Plaintiff. This Opinion and Order comprises the findings of 26 fact and conclusions of law required by Federal Rule of Civil Procedure 52(a).1 27 1 II. BACKGROUND 2 A. Plaintiff’s medical history 3 In 2020, Plaintiff was a 69-year-old pediatric physician in practice for over forty years. Her 4 last day worked was February 27, 2020. On March 3, 2020, Plaintiff underwent surgery for 5 uterovaginal prolapse and a hysterectomy. Her doctor, Dr. Matthew Clark, advised that Plaintiff 6 would be disabled following her surgery until at least May 21, 2020 to recover from the 7 procedure. 8 Plaintiff suffered several multiple medical issues leading up to and resulting in her surgery. 9 In December of 2019, Plaintiff presented to her OBGYN, Dr. Clark, several symptoms she was 10 experiencing, including a vaginal prolapse, complaints of urinary incontinence, fatigue, night 11 sweats, headaches, asthma, gastritis, as well as a history of cancer. AR 184. She requested a 12 hysterectomy based on an abnormal endometrial biopsy that showed precancerous changes in her 13 uterus. Following some further testing by Dr. Clark, Plaintiff’s surgery was scheduled for March 14 of 2020. 15 Shortly after Plaintiff’s surgery, the COVID-19 pandemic surged. On March 4, 2020, 16 Governor Newsom declared a state of emergency in California due to the rising number of 17 positive COVID-19 cases. On March 13, 2020, President Trump issued a proclamation declaring 18 the outbreak of COVID-19 a national emergency. Governor Newsom issued the statewide “Stay at 19 Home Order,” on March 19, 2020, ordering “all individuals living in the State of California to stay 20 home or at their place of residence except as needed to maintain continuity of operations of the 21 federal critical infrastructure sectors.” 22 The rapidly evolving health landscape had serious repercussions for Plaintiff’s wellbeing. 23 AR 228. In addition to the risks of COVID-19 posed by her vocation, Plaintiff suffered multiple 24 medical issues placing her at heightened risk of a severe COVID-19 infection including diabetes, 25

26 the . . . court may have placed on [them].” Tri–Tron Int’l v. Velto, 525 F.2d 432, 435–36 (9th Cir. 27 1975). 1 hypertension, asthma, obstructive sleep apnea, as well as her history of heart attack, cancer, and 2 fatty liver disease. The Center for Disease Control (CDC) issued guidance in 2020 listing several 3 of these conditions as COVID-19 risk factors that had the potential to lead to severe infection. 4 Plaintiff’s advanced age at the onset of her disability also put her at increased risk of COVID-19 5 infection, as 81% of COVID-19 deaths in 2020 occurred among those aged 65 and over. Betzaida 6 Tejada-Vera and Ellen A. Kramarow, COVID-19 Mortality in Adults Aged 65 and Over: United 7 States, 2020, Center for Disease Control, NCHS Data Brief No. 446 (October 2022). Given these 8 risk factors and Plaintiff’s potential exposure, she sought coverage under the Plan’s long-term 9 disability insurance policy. 10 B. The Policy’s terms 11 Per the terms of the Policy, Plaintiff was insured for long-term disability. The Policy 12 included a 90-day elimination period, which required the insured be disabled continuously for 90 13 days in order to be eligible for benefits. Due to Plaintiff’s age at the onset of her disability, she 14 could be eligible for a maximum of 12 months of benefits payments at 60% of her monthly pre- 15 disability earnings, totaling approximately $88,000 (60% of her pre-disability salary for 12 16 months). The Policy also defined a “total disability” as one resulting from sickness or illness and 17 premised on the insured being “unable to perform with reasonable continuity the substantial and 18 material acts” necessary for the insured to perform his or her occupation as usual. 19 C. Claim history 20 On May 22, 2020, Plaintiff submitted to Unum her claim for disability benefits. She 21 claimed her disability onset date as March 3, 2020, or the date of her surgery. On July 21, 2020, 22 she submitted her claim, along with an Attending Physician Statement (APS) from her 23 urogynecological surgeon, Dr. Clark, which explained that Plaintiff had undergone surgery on 24 March 3, 2020 and was restricted from heavy lifting or pushing, repetitive kneeling or squatting, 25 or extended sitting or standing during her recovery until May 21, 2020. Plaintiff also submitted an 26 APS from Dr. Nancy Cauncelbaum, her primary care physician, highlighting Plaintiff’s 27 heightened COVID-19 risks and complications as well as her depression as the basis for her 1 disability. Dr. Cauncelbaum opined that Plaintiff should be restricted from working from May 20, 2 2020 to January 1, 2021, at which point her condition be reassessed. 3 On August 24, 2020, Plaintiff submitted a Long-Term Disability Claim Form identifying 4 as the basis of her disability her high risk of exposure to COVID-19, metabolic syndrome, 5 Tamoxifen (a medication taken to protect Plaintiff from a recurrence of breast cancer), depression, 6 back pain, asthma, and heart attack. In September 2020, Dr. Cauncelbaum submitted to Unum yet 7 another form concluding that due to Plaintiff’s “chronic medical conditions, her age, and her work 8 as a pediatrician she is at high risk for COVID-19 complication” and that Plaintiff was accordingly 9 advised to “limit her patient exposure until the pandemic situation is improved.” Dr. Cauncelbaum 10 suggested that these conditions be reassessed in January of 2021. 11 Unum denied Plaintiff’s claim for benefits on November 10, 2020, stating in relevant part 12 that: 13 There is high risk of infection with COVID-19 with the insured's occupation. There is also risk of severe illness with COVID-19 due to 14 her medical conditions. However, the risks can be reduced with [personal protective equipment (“PPE”)] and preventative measures 15 as outlined by [the Occupational Safety and Health Administration (“OSHA”)]. Thus, given the ability to reduce the risks, our physician 16 reviewer opines that you are not precluded from performing the full- time duties of the occupation. 17 AR 347-49. Plaintiff provided Unum with further information in January of 2021, largely 18 regarding medical concerns other than those that would put her at risk for COVID-19, and filed a 19 formal appeal in March of 2021 to no avail. 20 D. Unum’s review of Plaintiff’s claim 21 On May 22, 2020, Plaintiff notified Unum of her claim.

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Downs v. Unum Life Insurance Company of America, Counsel Stack Legal Research, https://law.counselstack.com/opinion/downs-v-unum-life-insurance-company-of-america-cand-2024.