Hilton v. Unum Life Insurance Co. of America

967 F. Supp. 2d 1114, 2013 WL 4509507, 2013 U.S. Dist. LEXIS 120272
CourtDistrict Court, E.D. Virginia
DecidedAugust 22, 2013
DocketCase No. 1:12-CV-866 (GBL/JFA)
StatusPublished
Cited by3 cases

This text of 967 F. Supp. 2d 1114 (Hilton v. Unum Life Insurance Co. of America) is published on Counsel Stack Legal Research, covering District Court, E.D. Virginia primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Hilton v. Unum Life Insurance Co. of America, 967 F. Supp. 2d 1114, 2013 WL 4509507, 2013 U.S. Dist. LEXIS 120272 (E.D. Va. 2013).

Opinion

MEMORANDUM OPINION AND ORDER

GERALD BRUCE LEE, District Judge.

THIS MATTER is before the Court on Defendant UNUM Insurance Company of America’s (“UNUM”) , Motion for Summary Judgment (Doc. 21) and Plaintiff Janet Hilton’s (“Hilton”) Cross Motion for Summary Judgment (Doc. 58). This case involves the interpretation and application of an express limitation to Plaintiffs long-term disability benefits by the administrator of an employee welfare benefit plan governed by the Employee Retirement Income Security Act (“ERISA”), 29 U.S.C. §§ 1001-1461 et seq. 1001. There are three issues before the Court.

The first issue is whether Defendant UNUM reasonably interpreted and applied its policy language, temporally limiting Plaintiffs benefits based on her condition being primarily supported by self-reported symptoms. The Court holds that based on the administrative record before it at the time, UNUM did not abuse its discretion or act unreasonably because UNUM properly exercised its discretion in terminating Ms. Milton’s benefits based on its reasonable interpretation of its own policy language, which the Court affords great deference, and because the administrative record reveals that migraine headaches are not objectively verifiable, such that Plaintiffs condition falls within the purview of the policy’s limitation.

The second issue is whether UNUM’s decision-making process was reasoned and principled. The Court concludes that UNUM’s process was reasoned and principled because UNUM investigated Ms. Hil[1116]*1116ton’s claim using both the information contained in Plaintiffs medical claim file and the medical evaluation of her claim. Therefore, the Court concludes that UNUM’s process was reasoned and principled.

The third issue is whether UNUM improperly based its decision on a conflict of interest. The Court concludes that UNUM did not make its decision based on a conflict of interest, and the administrative record did not indicate that UNUM had bias toward Plaintiff. The Court also reaches this conclusion because UNUM consulted with two board-certified physicians to address Ms. Hilton’s appeal and analyzed Ms. Hilton’s medical documentation in generating its decision to Ms. Hilton’s claim.

I. BACKGROUND

A. Statement of Facts

Ms. Hilton began working for the American Society of Civil Engineers (“ASCE”) on or around October 2, 2000. She served as the ASCE Art Director. (Compl. ¶ 5.) ASCE entered into an insurance contract with UNUM that provided long-term disability insurance benefits. (Id. at ¶ 6.) The Disability Insurance Plan (“the Plan”) constitutes an “employee welfare benefit plan” and is subject to various provisions of ERISA. (Id. ¶ 7.) Ms. Hilton was a plan participant and at all times, UNUM was the claims fiduciary for administration of the claims for disability benefits under the terms of the Plan. (Id. ¶ 9.) UNUM made all of the decisions regarding Ms. Hilton’s claim for disability benefits. (Id. ¶¶ 8-10.)

Ms. Hilton suffers from migraine headaches. On December 5, 2008, UNUM approved Plaintiffs long-term disability benefits based on this condition, and payments to Ms. Hilton began on October 16, 2008. (Id. at ¶ 12.) On October 21, 2010, UNUM terminated Ms. Hilton’s benefits, stating that she reached the maximum twenty-four month period of payment for disabilities based primarily on self-reported symptoms. (Id. at ¶ 13.) Pursuant to the Plan, “self-reported symptoms” are defined as:

the manifestations of your condition which you tell your physician, that are not verifiable using tests, procedures or clinical examinations standardly accepted in the practice of medicine. Examples of self-reported symptoms include but are not limited to headaches, pain, fatigue, stiffness, soreness, ringing in ears, dizziness, numbness and loss of energy.

(AR at 120.)

Ms. Hilton appealed the termination of her benefits to UNUM on April 21, 2011. Plaintiff also underwent two prior MRIs showing the existence of white-matter abnormalities. Based on this MRI finding, Plaintiff argued on appeal that her migraines were not based primarily on self-reported symptoms because her condition was verifiable by MRI. Plaintiff contends that with objective verification of migraines by these MRI studies, the self-reported limitation does not apply. By definition, manifestations of the disabling condition that are verifiable by testing are excluded from the limitation. Where there exists objective tests or clinical examinations standardly accepted in the practice of medicine, Unum’s self-reported symptom limitation does not apply. (Def.’s Mot. Summ. J. at 13, Doc. 22.)

UNUM assigned an Appeals Specialist, Ms. Mininni, to conduct a review of Ms. Hilton’s appeal. (Administrative Record [hereinafter “AR”] at 2022-23.) Ms. Mininni consulted a board-certified physician, Dr. Schnars, who provided a clinical summary of Ms. Hilton’s treatment. (AR at 2036-39.) The summary indicates that [1117]*1117Ms. Hilton’s symptoms are specifically listed as self-reported symptoms according to the Policy and as a result, her benefits are limited to twenty-four months. (AR at 2114.) Ms. Mininni asked Dr. Schnars to respond to a series of questions. In response to whether the medical evidence in the file support disabling restrictions as of 10/15/2010, Dr. Schnars noted that “there are no physical disabling restrictions supported.” (AR at 2039.) In response to the question of whether there is sufficient medical evidence to substantiate a diagnosis of migraine, Dr. Schnars answered, in part, “early description of headaches at initial evaluation describe chronic daily headaches with migraine component and the diagnosis of migraine headache or other primary type headaches is based on historical information.” (Id.) In response to whether the available medical evidence (such as signs, diagnostics, and physical exam findings) correlate with the insured reported level of functional loss, Dr. Schnars answered, “there are no physical exam findings, laboratory or diagnostic testing to correlate with severity of reported symptoms or loss of functionality and self-reports of severity of pain and function are depended upon by treating physician for assessment and medication adjustment.” (Id.)

In addition to Dr. Schnars’ summary, UNUM also included a consultation of Plaintiffs claims with another board-certified physician, Dr. Re. The three questions posed to Dr. Re and his responses thereto are set forth below:

What are the client’s symptoms of migraine/chronic daily headaches?
The medical records do not document the character of the headaches very well. No auras111 are described and no location is noted other than to state that she has sharp shooting pains in her head. No precipitating factors are noted i.e. light, sound or smells. She did report associated nausea, vertigo, and poor sleep. She described her headaches as migraines that varied from weekly to daily. A variety of functional complaints were contributed to her headaches. There was some history of self-medicating with alcohol and problems with excessive use of pain relievers. Can the symptoms be verified by diagnostics, medical data, etc. ?
No.

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

Related

Cite This Page — Counsel Stack

Bluebook (online)
967 F. Supp. 2d 1114, 2013 WL 4509507, 2013 U.S. Dist. LEXIS 120272, Counsel Stack Legal Research, https://law.counselstack.com/opinion/hilton-v-unum-life-insurance-co-of-america-vaed-2013.